Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 1 - OMB #: 0938-0707 Exp. Date: MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM Preamble Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment. This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI. The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments. Form CMS-R-211

Missouri Application for the State Children’s Health Insurance Program Effective Date: 07/01/2011 Approval Date: Bold Italics Added Information Prior Approval Date: 09/24/2009 Strikethrough Deleted Information - 2 - MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM (Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b))) State/Territory: MISSOURI

(Name of State/Territory) As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b)) _________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed) submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Brian Kinkade Position/Title: Interim Director, Department of Social Services Name: Ian McCaslin, M.D., M.P.H Position/Title: Director, MO HealthNet

Division According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 3 - Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101) 1.1 The State will use funds provided under Title XXI primarily for (check appropriate box): (42 CFR 457.70) 1.1.1 □ Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR 1.1.2 □ Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR 1.1.3  A combination of both of the above. Response:

1. Separate SCHIP Program 2. Medicaid Expansion Program As a result of the passage of Senate Bill (SB) 577 during Missouri's 94th Legislative Session in 2007, Missouri's Medical Assistance Program, formerly 1SCHIP 1: Children under age 1 Children in families with gross incomes of more than 185% but less than 300% FPL 1SCHIP 1: Children ages 1 through 5 Children in families with incomes of more than 151% but less than 300% FPL 2SCHIP 2: Children ages 1 through 5 Children in families with incomes more than 133% but less than 151% FPL 1SCHIP 1: Children ages 6 through 18 Children in families with incomes of more than 151% but less than 300% FPL 2SCHIP 2: Children ages 6 through 18 Children in families with incomes of more than 100% but less than 151% FPL

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 3A - known as Missouri Medicaid, is now known as MO HealthNet. The title of the Division of Medical Services is now known as the MO HealthNet Division. Presumptive Eligibility Missouri provides presumptive eligibility for children in families with income of 150% of FPL or below until an eligibility decision is made. Missouri proposes that uninsured children age birth through age 18 with family income below 150% of the Federal Poverty Level (FPL) be covered under the MO HealthNet expansion. SCHIP 2 Children eligible for SCHIP 2 will receive the MO HealthNet package of essential medically necessary health services, including Non-Emergency Medical Transportation (NEMT). Prescription drugs will be subject to the national drug rebate program requirements. Fee-for-service will be utilized in regions where MO HealthNet managed care is not yet available. When MO HealthNet managed care begins in these areas, Title XXI eligibles will be enrolled in MO HealthNet managed care. No new eligible will be excluded because of pre-existing illness or condition.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 4 - SCHIP 1 Missouri proposes that uninsured children under age 1 with family income more than 185% but less than 300% of FPL and uninsured children age 1 through age 18 with family income between 151% and 300% of the federal poverty level be covered under a Separate Child Health Program. No new eligible is excluded because of pre-existing illness or condition. Children in families with income above 150% of FPL are not eligible if they have access to affordable insurance. Children eligible for SCHIP 1 receive a benefit package of essential medically necessary health services, excluding NEMT. This benefit is so unheard of in any health insurance plan that its inclusion serve as a significant incentive for dropping of private coverage. Prescription drugs are subject to the national drug rebate program requirements. Fee-for- service is utilized in regions where MO HealthNet Managed Care is not yet available. When MO HealthNet Managed Care begins in these areas, Title XXI eligibles will be enrolled in MO HealthNet Managed Care. A joint application is used to apply for the federal/state Title XIX and Title XXI programs. SCHIP 1 requires a premium, but does not impose co-payments, co-insurance, or deductibles. The program does not require an asset test. An asset test and a resource standard are the same. In Missouri, programs that have an asset test or resource standard compare the family’s available assets or resources to a standard. Certain assets or resources may be excluded when determining if the family’s assets or resources are below the maximum allowable to qualify for the program. Missouri does not have an asset test or resource standard for SCHIP 1. The net worth test for SCHIP 1 is $250,000. The net worth test for SCHIP 1 children in families with income that exceeds 150% of the Federal Poverty Level (FPL) is calculated by considering the value of all assets or resources minus any debt owed. There are no assets or resources excluded when determining net worth for SCHIP 1. SCHIP 1 requires children to be uninsured for six months prior to enrollment, except for children with special health care needs or when good cause for dropping insurance is found.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 4A - 1.2  Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS (42 CFR 457.40(d)) 1.3  Please provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the

Missouri Application for the State Children’s Health Insurance Program Effective Date: 07/01/2011 Approval Date: Bold Italics Added Information Prior Approval Date: 09/28/2007 Strikethrough Deleted Information

- 5 - Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42 CFR 457.130) 1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment. (42 CFR 457.65) Response: Effective date (date State incurs costs): Initial Combination SCHIP State Plan Submission, SPA #3: September 1, 2007 SPA #4: Disapproved December 19, 2008 SPA #5: Effective May 1, 2009 SPA #6: Effective July 1, 2009 SPA #7: Withdrawn June 29, 2011 SPA #8: Effective July 1, 2011 Implementation date (date services begin): SPA #3: September 1, 2007 SPA #4: Disapproved December 19, 2008 SPA #5: May 1, 2009 SPA #6: July 1, 2009 SPA #7: Withdrawn June 29, 2011 SPA #8: Effective July 1, 2011

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 6 - Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) 2.1 Describe the extent to which, and manner in which, children in the State including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a)) Response: Information regarding age, income, coverage by other health insurance, and location is currently available from Missouri’s Application for Benefits and will be required for Title XXI applicants. The State will require that any recipient cooperate fully with the state and federal government in establishing eligibility and in providing any verification necessary as requested by the State in the initial application process or at any subsequent time. Title XXI recipients will have distinct ME codes for tracking purposes. Please see Attachment 1. Unfortunately, the extant data is quite limited. We summarize the available data below:  Missouri does not conduct its own recurring prevalence study for health insurance among resident children. However, the Missouri Department of Health and Senior Services (DHSS) commissioned a study in 2004 under a State Health Planning Grant from the Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (DHSS). This study, the Missouri Health Care Insurance and Access (MHCIA) survey, asked questions regarding health insurance coverage of roughly 7,000 respondents. The survey found that the rate of uninsurance among Missouri children under age 19 was 3.4 percent (no standard error or confidence interval reported). The MHCIA study also reported a slightly higher rate (4.0 percent) among children in households with incomes below 300 percent of the federal poverty level. However, the sample size was too small to generate meaningful rates for additional subpopulations. The MHCIA report noted that, “Missouri’s public programs cover a larger proportion of children (28.5%), while rates of group (63.9%) and individual coverage (4.2%) for children are similar to the rates of the adult population.” The one-year nature of the study prohibits any trending or longitudinal analyses. For additional information, see http://www.dhss.mo.gov/DataAndStatisticalReports/Missouri_Final_Report.pdf. Note: The Missouri Foundation for Health analyzed and compared

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 6A- estimates from the CPS and the MHCIA surveys; its report is available at http://www.mffh.org/ShowMe8-final.pdf.  The Census Bureau's annual Current Population Survey (CPS), specifically the Annual Social and Economic Supplement (ASEC), also provides information about health insurance status based on a survey of approximately 78,000 households nationally. For 2006, the CPS estimate for the rate of uninsured children in households with income under 200% of the federal poverty level was 33.4 percent (+/– 5.9%). Because of the relatively small sample size, the calculated rates of uninsured children by sex, race, age, etc. have such large confidence intervals that the individual point estimates are essentially without meaning and may prove highly misleading. For additional information, see http://www.census.gov/cps/. Given the paucity of data, we are unable to present the rate of uninsured children in Missouri stratified by sex, race, age, etc. (because the width of the confidence intervals would make any point estimates essentially meaningless). With respect to the changes in the health insurance status of Missouri children since the SCHIP program went into effect in 1999, we evaluated the Census Bureau’s historical CPS data:  Looking at the most recent data, the rate of uninsured children in Missouri appears to have fluctuated somewhat over the past three years. The 2005 rate of 7.6 percent is down from the 2004 rate of 8.5 percent but still up from the 2003 rate of 7.3 percent. The rate continues to be about one-third less than the national average of 11.2 percent (see Figures 1 and 2).

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 6B- Figure 1 Number of Uninsured Children in Missouri, 1990-2005 191 170 176 129 117 181 168 178 123 46 101 66 69 103 120 106 - 50 100 150 200 250 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year Number (Thousands) Source: U.S. Census Bureau, Historical Health Insurance Tables, Table HI-5. Health Insurance Coverage by State -- Children Under 18: 1990 to 2005. Available at: http://www.census.gov/hhes/hlthins/historic/hihistt5.html.

Figure 2 9.3% 9.7% 11.7% 13.0% 8.9% 3.2% 7.1% 4.7% 5.0% 7.3% 8.5% 7.7% 13.0% 12.7% 12.7% 13.7% 14.2% 13.8% 14.8% 15.0% 15.4% 12.8% 11.9% 11.7% 11.6% 11.4% 10.8% 11.2% 13.1% 14.1% 13.1% 14.4% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 MO USA Percent of Uninsured Children, USA and Missouri, 1990-2005 Source: U.S. Census Bureau, Historical Health Insurance Tables, Table HI-5. Health Insurance Coverage by State -- Children Under 18: 1990 to 2005. Available at: http://www.census.gov/hhes/hlthins/historic/hihistt5.html.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 6C -  Taking a longer-term view, Missouri has made great strides in reducing the number of uninsured children since the mid-1990’s. The average rate during the seven years prior to full implementation of the 1115 Waiver (1992-1998) is nearly twice as high as the average rate during the seven year period since implementation of the 1115 Waiver (1999-2005): the average rates for these two periods are 11.5 percent and 6.2 percent, respectively. The lower average rate since 1999 is at least partly attributable to the 1115 Waiver, which has provided insurance coverage to children who were either previously uninsured or had lost other coverage and would be uninsured in the absence of the 1115 Waiver. For reference, additional information about the Waiver during this period is available in the “Evaluation of the Missouri Section 1115 Waiver, 2004-05,” which is available http://dss.mo.gov/dms/mc/pdf/eval_1115_04-05.pdf. Specifically, see Research Question #1. As a proxy for the rate of uninsured children in Missouri by by race, we analyzed inpatient discharges in Missouri among children under age 15. This indicator is useful because Missouri hospitals routinely collect and report these data for all patients. Additionally, because inpatient utilization is rarely elective, these data are indicative of the underlying prevalence of payers in Missouri. Accordingly, we used data reported in the Missouri Information for Community Assessment (MICA) to generate:  Rates of such discharges by payer by year (see Table 1);  Rates of such discharges among self-pay patients by race by year (see Table 2); and  Two-year rates of such discharges among self-pay patients by race by sex (see Table 3). Please note that “Self-Pay, Etc.” in Table 1 includes the following responses: self-pay, unknown, and other. Table 2 includes data for only those indicating “self-pay” as their payer. Based on our analyses, it seems that the rate of inpatient discharges among self-pay children has increased consistently for all races and sexes since 2002. This change largely reversed the earlier declines. Additionally, it appears that the self-pay population remains sizeable and appears to be using, on average, increasing levels of inpatient utilization. However, we are unable to extrapolate from these data any changes in the demographic composition of the population of uninsured children in Missouri.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 6D - Table 1 Rate of Inpatient Discharges by Payer for Missouri Children under 15 in Missouri (1994-2005) - 50.0 100.0 150.0 200.0 250.0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Rate per 10,000 Medicaid Other Gov't Commercial Self-Pay, etc. Source: DHSS MICA Data

Table 2 Rate of Inpatient Discharges by Race for Self-Pay Children under 15 in Missouri (1994-2005) - 5.0 10.0 15.0 20.0 25.0 30.0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Rate per 10,000 White Black All Races Source: DHSS MICA Data

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 6E - Table 3 Two-Year Rates of Inpatient Discharges for Self-Pay Children under 15 in Missouri (2000-06) - 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 White Female White Male Black Female Black Male Rate per 10,000 2000-01 2002-03 2004-05 Source: DHSS MICA Data

Our analysis of Current Population Survey (CPS) data indicates approximately 1.35 million (or 92 percent) Missouri children age 18 and under had some form of creditable coverage during the year. Of those with creditable coverage, approximately 1.02 million (about three-quarters) had some form of private insurance. Employer-sponsored insurance (ESI) constitutes over 90 percent of the private coverage among Missouri children. For reference, the total population of children age 18 and under in Missouri is approximately 1.46 million. Tables 1 and 2 provide break-downs of the CPS data by poverty level, race, and sex for (i) children insured and (ii) all children in Missouri, respectively. Looking specifically at the target population, the CPS data suggest that roughly 730,000 (or close to 90 percent) of Missouri children under 300 percent of the federal poverty level had some form of creditable coverage during the year. Of these, about 430,000 (roughly 60 percent) were privately-insured. As with the general population, about 90 percent of privately-insured children in the target population accessed coverage through ESI. Table 3 provides a summary of these data by poverty level. The estimates above are three-year averages derived from data collected as part of the Annual Social and Economic Supplement (ASEC) from 2004 to 2006. Because of the relatively small sample sizes, the calculated rates of insured

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 6F - children by poverty level, race, and sex have quite large confidence intervals; consequently, some of the individual point estimates may prove highly misleading. For additional information, see http://www.census.gov/cps/.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 6G - Table 1: Missouri Children (age 18 and under) with Creditable Coverage Poverty Threshold Total White alone Black/ African Amer alone Amer Indian/ Alaska Native alone Asian alone Native Hawaiian/ Other PI alone Two or more races All Income Levels Totals 1,351,245 1,100,440 192,921 4,363 11,498 337 41,687 Male 674,513 547,606 94,633 2,720 7,598 337 21,620 Female 676,732 552,834 98,288 1,643 3,900 0 20,067 Below 100% Totals 212,552 130,472 73,620 817 1,427 0 6,215 Male 99,589 60,112 35,107 817 435 0 3,118 Female 112,963 70,361 38,512 0 992 0 3,098 100% to below 200% Totals 248,364 193,166 44,731 1,710 2,533 337 5,887 Male 127,146 102,184 20,701 1,454 1,062 337 1,407 Female 121,218 90,982 24,030 256 1,471 0 4,479 200% to below 300% Totals 270,927 216,026 40,696 301 1,576 0 12,328 Male 139,112 110,950 18,243 0 1,120 0 8,798 Female 131,815 105,076 22,453 301 455 0 3,530 300% to below 400% Totals 234,519 200,738 24,154 428 946 0 8,252 Male 112,685 93,515 14,991 0 542 0 3,637 Female 121,834 107,223 9,163 428 404 0 4,616 400% to below 500% Totals 152,132 141,519 4,707 659 3,182 0 2,065 Male 82,148 75,632 3,088 0 2,605 0 822 Female 69,984 65,888 1,618 659 577 0 1,242 500% and above Totals 232,751 218,517 5,012 449 1,833 0 6,940 Male 113,834 105,213 2,501 449 1,833 0 3,838 Female 118,918 113,305 2,511 0 0 0 3,102 Source: U.S. Census Bureau Current Population Survey, Annual Social and Economic Supplement, 2004 through 2006.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 6H - Table 2: Missouri Children (age 18 and under) - Total Poverty Threshold Total White alone Black/ African Amer alone Amer Indian/ Alaska Native alone Asian alone Native Hawaiian/ Other PI alone Two or more races All Income Levels Totals 1,463,297 1,186,760 210,554 7,377 13,697 337 44,571 Male 735,256 595,516 103,502 4,024 9,039 337 22,838 Female 728,041 591,244 107,052 3,353 4,658 0 21,733 Below 100% Totals 243,576 156,701 77,169 817 1,863 0 7,026 Male 117,274 74,995 37,111 817 871 0 3,480 Female 126,302 81,706 40,058 0 992 0 3,546 100% to below 200% Totals 287,832 218,887 54,739 3,252 3,182 337 7,434 Male 148,624 116,479 25,602 2,758 1,711 337 1,737 Female 139,208 102,409 29,137 494 1,471 0 5,697 200% to below 300% Totals 294,041 235,610 43,700 301 1,576 0 12,854 Male 151,849 121,196 20,208 0 1,120 0 9,324 Female 142,192 114,414 23,491 301 455 0 3,530 300% to below 400% Totals 244,238 207,912 25,227 1,900 946 0 8,252 Male 117,942 98,772 14,991 0 542 0 3,637 Female 126,296 109,140 10,236 1,900 404 0 4,616 400% to below 500% Totals 158,206 146,478 4,707 659 4,297 0 2,065 Male 84,488 77,615 3,088 0 2,962 0 822 Female 73,718 68,863 1,618 659 1,335 0 1,242 500% and above Totals 235,404 221,171 5,012 449 1,833 0 6,940 Male 115,080 106,459 2,501 449 1,833 0 3,838 Female 120,325 114,712 2,511 0 0 0 3,102 Source: U.S. Census Bureau Current Population Survey, Annual Social and Economic Supplement, 2004 through 2006.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 07/01/2011 Approval Date: Bold Italics Added Information Prior Approval Date: 05/01/2009 Strikethrough Deleted Information - 6I - Table 3: Type of Coverage among Insured Missouri Children < 300% FPL

Total Insured Health Insurance: Private Insurance Health Insurance: Employment-Based Insurance Totals

1,463,297

1,351,245

1,021,216

937,014 Below 100%

243,576

212,552 46,899 38,147 100% to below 200%

287,832

248,364

147,768

131,685 200% to below 300%

294,041

270,927

233,645

210,127 300% to below 400%

244,238

234,519

224,371

211,942 400% to below 500%

158,206

152,132

140,453

129,561 500% and above

235,404

232,751

228,080

215,552 Subtotal: < 300% FPL

825,449

731,843

428,312

379,959 Source: U.S. Census Bureau Current Population Survey, Annual Social and Economic Supplement, 2004 through 2006.

2.2 Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

Pursuant to Section 2105(a)(1)(D)(ii), Missouri will offer “Health Services Initiatives” under the plan. The Health Services Initiatives will be activities for improving the health of children that are administered by Local Public Health Agencies (LPHAs) and funded by local and state funds. Specific Health Services Initiatives may include the following programs:

Immunization programs

LPHAs provide a vital role in immunizing our children and promoting immunization among hard to reach families and communities. Immunization program costs are operational (staff related) costs only. The vaccines costs for CHIP 2 are funded through the Vaccines for Children (VFC) program, therefore the costs of the vaccines are not included in the CHIP claiming. The immunization program costs claimed under CHIP are net of revenue obtained from billing Medicaid and other insurers for administrative costs. Children enrolled in CHIP 1 are not eligible for vaccines through the VFC program.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 6J - Lead testing and prevention programs

LPHAs are at the forefront of monitoring and managing lead poisoning among children up to the age of six. Lead program costs include educating families about lead poisoning, testing, and case management services. The lead related program costs claimed under CHIP are net of applicable credits.

Newborn home visiting programs

LPHAs offer newborn home visiting programs to high risk families. Clinical staff and other trained professionals provide a range of services to young families to ensure the healthy development of infants and toddlers.

School health programs LPHAs provide health related services in schools and pre-schools including health education, screenings, maintenance of health records, basic nursing services and referrals as needed to other health care providers. These services are distinct and different from the services provided in schools as part of special education services authorized under IDEA.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date: Bolded/Italics Added Information Prior Approval Date: 09/28/2007 Strikethrough Deleted Information - 11 - Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4)) □ Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4. 3.1 Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42 CFR 457.490(a)) Response: The Missouri DSS, MO HealthNet Division has identified eight guiding principles for the MO HealthNet, SCHIP 1, and SCHIP 2. The following principles apply to the program whether financed through Title XIX or Title XXI. 1) All recipients must have a medical home. 2) Attention to wellness of the individual (i.e., education). 3) Chronic care management. 4) Care management (resources focused towards people receiving the services they need, not necessarily because the service is available). 5) Appropriate setting at the right cost. 6) Emphasis on the individual person. 7) Evidenced based guidelines for improved quality care and use of resources. 8) Encourage responsibility and investment on the part of the recipient to ensure wellness. The delivery systems described below apply to MO HealthNet, SCHIP 1, and SCHIP 2. MO HealthNet Fee-For-Service Delivery System Individuals eligible for the SCHIP 1 and SCHIP 2 receive their care through the MO HealthNet Fee-For-Service delivery system in regions of the State where MO HealthNet Managed Care is not operational. In areas of the State where MCOs are not operational, participants may freely choose which MO HealthNet approved providers they go to for care under the MO HealthNet Fee-For-Service delivery system. MO HealthNet Managed Care Program Recipients are enrolled in MCOs that are contracted with the State of Missouri. Enrollment in the MO HealthNet Managed Care Program is mandatory for individuals who reside in areas of the State where MO HealthNet Managed Care is operational. Please see Attachment 2. Each MCO contracts with Primary Care Providers (PCP), specialists, and other providers to deliver and coordinate health care services for recipients. The MCO receives a per

Missouri Application for the State Children’s Health Insurance Program Effective Date: 07/01/2011 Approval Date: Bold Italics Added Information Prior Approval Date: 05/01/2009 Strikethrough Deleted Information - 12 - member per month (PMPM) capitation rate for providing and coordinating health care services for members. Recipients are given an opportunity to select an MCO in his or her area of the State, as well as a PCP within that MCO. Once eligibility is established, recipients receive an enrollment packet which includes a listing of available MCOs, instructions on how to choose an MCO, and who to contact for assistance in determining if their current health care provider is participating in an MCO. Recipients may choose an MCO any time during their open enrollment period by sending in the enrollment form or contacting the Enrollment Broker to enroll over the telephone. For those individuals who do not make an MCO selection, the State uses an algorithm to assign the member to an MCO. Recipients will be covered on a Fee-For-Service basis until enrollment in the MCO is effective. The contracted Enrollment Broker handles the MCO self selection function. All members will be enrolled in an MCO for a period of 12 consecutive months to provide a solid continuum of care. Once a member chooses an MCO or is assigned to an MCO, the member has 90 calendar days from the effective date of coverage to change MCOs for any reason. Children in State care and custody are allowed automatic and unlimited changes in MCO choice as often as circumstances necessitate. The MCOs must assure that members are offered freedom of choice in selecting a PCP. Each MCO shall limit its PCPs to licensed residents specializing in family and general practice, pediatrics, obstetrics and gynecology (OB/GYN), and internal medicine; registered nurses who are advance practice nurses with specialties in family practice, pediatric practice, and OB/GYN practice; and licensed physicians in the following specialties: family and general practitioners, pediatricians, OB/GYN, and internists. 3.2 Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42 CFR 457.490(b))

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 13 - Response: Utilization controls for targeted low-income children will vary depending on the health care delivery system from which targeted low-income children receive healthcare. MO HealthNet Fee-For-Service Delivery System The MO HealthNet utilization review program in the fee for service setting has a multi- prong approach very similar to those used by the MO HealthNet Managed Care delivery system. Utilization management programs in place includes pre-certification allowing payment for services and equipment that are medically necessary, appropriate, and cost- effective without compromising the quality of care to those served in the fee-for-service setting. The MO HealthNet Division has introduced an electronic health record program. The online tool called CyberAccess sm is available to request or check status of a pre- certification request. An innovative Electronic Health Record (EHR) program for MO HealthNet recipients is available to their healthcare providers. The web-based tool allows physicians to prescribe electronically, view diagnosis data, receive alerts, select appropriate preferred medications, and electronically request drug and medical prior authorizations for their fee-for-service patients. CyberAccess sm is the first step toward a comprehensive electronic health record for MO HealthNet recipients. In addition, the MO HealthNet Division contracts for utilization review of inpatient stays. The contractor's medical review staff must make decisions for inpatient hospital admission and continued stays in accordance with the Severity of Illness/Intensity of services screening criteria (using the most recent edition of the InterQual ISD Pediatric Acute Level of Care and Adult Level of Care) based on pertinent medical information received from the attending physician or hospital regarding the patient's condition and planned services, and in the case of continued stay reviews, whether any further care planned may be safely provided in a post hospital setting. The Department of Health and Senior Services operates a Healthy Children and Youth (HCY) Administrative Case Management Program assists families in meeting their child's needs to function at an optimal level. Assistance is provided for:  Access to screening services  Follow-up on referrals to additional medical providers  Establishment of a medical home  Service plan development  Follow through on the treatment plan

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 13A - Treatment is determined by the primary care provider. As a part of the Administrative Case Management role, the Special Healthcare Needs (SHCN) staff assists in securing the following services:  Home health services  Private duty nursing  Personal care service  Advanced personal care services  HCY Case Management through Local Public Health Agencies Eligibility: This program is available to all MO HealthNet eligible children residing in Missouri who are in need of medically necessary services from MO HealthNet providers. Service Coordination:  Assisting recipients/families in identifying and accessing medically necessary services  Establishing a medical home  Connecting families with appropriate community resources  Meeting with the recipient and family on an ongoing basis to plan, promote, assist and assure the implementation of services Service (Case) Planning: Developing an interdisciplinary plan for coordination of the required medical services. Service Identification: Following assessment and service planning, the SHCN service coordinator will identify the type, amount, intensity, and duration of services required to meet the case plan goals. The SHCN Service Coordinator/HCY Facilitator will identify potential service providers from which the family may choose. Prior Authorization: The SHCN Service Coordinator authorizes the following services:  Private duty nursing  Advanced personal care aide  Personal care aide

Missouri Application for the State Children’s Health Insurance Program Proposed Effective Date: 05/01/2009 Approval Date: Bolded/Italics Added Information Prior Approval Date: 09/28/2007 Strikethrough Deleted Information - 13B -  Skilled nursing visits  Administrative Case Management Service Monitoring: Service coordinators monitor services through regular home visits MO HealthNet Managed Care Delivery System The standard MO HealthNet, SCHIP 1, SCHIP 2 utilization review policies and procedures are encompassed in the currently certified and operational MO HealthNet Management Information System (MMIS) Surveillance/Utilization Review Subsystem (SURS). Under the MO HealthNet Managed Care delivery system, the MCOs are required by contract to have Utilization Management Programs and written prior authorization, certification, utilization management, and care management policies and procedures. The policies and procedures include protocols and criteria for evaluating medical necessity, authorizing services, case management, care coordination, disease management, and detecting and addressing over and under utilization. Such protocols and criteria comply with federal and state laws and regulations. The MCOs provide assistance to enrollees and providers to ensure the appropriate utilization of resources using prior authorization; prospective, concurrent and retrospective review; discharge planning; provider and patient profiling; and use of clinical practice guidelines.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 07/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 14 - Section 4. Eligibility Standards and Methodology. (Section 2102(b)) □ Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5. 4.1 The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42 CFR 457.305(a) and 457.320(a)) 4.1.1  Geographic area served by the Plan: Response: SCHIP 1 and SCHIP 2 are available statewide. 4.1.2  Age: Response: MO HealthNet's SCHIP 1 is available to children age birth through age 18. MO HealthNet's SCHIP 2 is available to children age one through age 18. 4.1.3  Income: Response: The State's upper gross income limit is 300% of FPL. The standard income disregard equal to 100% of the FPL is made from the gross income figure of 300% of FPL. The net income figure will be compared to 200% FPL to determine if the child(ren) is (are) eligible. To be eligible, this net figure must not exceed 200% FPL for children. All wages paid by the U. S. Census Bureau for temporary employment related to Decennial Census activities are excluded in years in which there is a federal census. 4.1.4 □ Resources (including any standards relating to spend downs and disposition of resources): 4.1.5  Residency (so long as residency requirement is not based on length of time in state): Response: Eligible children must be a Missouri resident 4.1.6 □ Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7  Access to or coverage under other health coverage: Response: Eligible children must be uninsured and not have access to affordable insurance. 4.1.8  Duration of eligibility: Response: Children are deemed eligible until FSD determines otherwise. FSD makes eligibility determinations on all applications within 30 days. Re-determinations, which are known in Missouri as reinvestigations, are conducted annually whether a change is reported or not. Once determined eligible, children are deemed to remain eligible until

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 14A - FSD determines they are no longer eligible due to no longer meeting eligibility criteria caused by a change in household circumstances or other change. However, the family does not need to re-apply and this is what is meant by “deemed eligible until FSD determines otherwise”. Families are required to report changes, and FSD makes a determination of continued eligibility considering the change. Lastly, SCHIP 1 and SCHIP 2 cases are closed following a notice to the family if the family fails to complete an annual reinvestigation. 4.1.9  Other standards (identify and describe): Response: Other standards (identify and describe): A Social Security Number and documentation of citizenship and alien status for children who are covered by SCHIP 1 and SCHIP 2. A net worth test of $250,000 is also required. Children with special healthcare needs must still be uninsured to qualify and cannot have access to affordable health insurance. Access to affordable insurance available through employment, a group membership, or from a private company causes ineligibility. In addition, children in families with gross income above 150% of the FPL cannot have access to affordable employer sponsored or private health insurance. These children must pay a premium to be eligible (a cost sharing provision). The following is a description of the affordability test for both groups: • Three percent of 150% of the FPL for a family of three, for families with a gross income of more than 150% and up to 185% FPL. • Four percent of 185% of the FPL for a family of three, for families with a gross income of more than 185% and up to 225% FPL. • Five percent of 225% of the FPL for a family of three, for families with a gross income of more than 225% but less than 300% FPL. 4.2 The State assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42 CFR 457.320(b)) 4.2.1  These standards do not discriminate on the basis of diagnosis.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 15 - 4.2.2  Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3  These standards do not deny eligibility based on a child having a pre- existing medical condition. 4.3 Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42 CFR 457.350) Response: The methods of establishing eligibility and continuing enrollment for SCHIP 1 and SCHIP 2 is the same as for all MO HealthNet recipients. There are several ways to obtain an application. The application is available online and can be downloaded from the DSS website at http://www.dss.mo.gov/mhk/appl.htm. Individuals can call a toll free number in Missouri to request that an application be mailed to them, or they may call their local FSD Office to request that an application be mailed. Applications are available at hospitals, local public health agencies, mental health facilities, and schools. Individuals may also apply by visiting their local FSD Office. Applications are available in English, Spanish, Bosnian, or Vietnamese, and translation services are available. The application is a two-page document that asks for: • Mailing address; • All children, parents/guardians and stepparents who live in the home; • The Social Security Numbers (SSN) and citizenship or immigration status of those persons applying for coverage. SSNs are required only for MO HealthNet applicants. SSNs are not required for any individual who is not applying for assistance. The parent’s SSN can be used to assist in verifying the family’s income. However, the parent's SSN is not required. The instructions explaining whose SSNs are required are attached to the application. For simplification, FSD limits the application to one page. There is not room on one page for the instructions and the application. 42 CFR 457.340(b) does not prohibit asking for the parent's SSNs; it only prohibits a state requiring the SSN from a non-applicant. • Information about employment, child care costs, other income, net worth, health insurance coverage, and absent parent information Applications are processed and eligibility determinations are made within 30 days of receipt. FSD requires documentation (verification) of citizenship or immigration status and income. Applicants are notified in writing when a decision is made. Applications are considered complete when they are signed by the claimant. If information is needed to make a determination of eligibility, the claimant is provided a written request for the information and given at least 10 days to

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 15A - provide it. The claimant is informed about reporting requirements and that it is against the law to obtain benefits to which they are not entitled. FSD staff provides information about income guidelines and the eligibility criteria as well as time limits for processing an application. FSD requires documentation of citizenship or immigration status for eligible children and verification of the family’s income. FSD does not have a durational requirement for residency. The eligible family members must state they are Missouri residents. It is important to note that the State is concerned that SCHIP 1 does not “crowd out” private insurance options. The following measures will help address crowd out of private insurance options: • There will be a six month look back period for health insurance when determining eligibility. Children whose parents’ available private health insurance coverage was dropped within the last six months will have a six month waiting period under SCHIP 1. Uninsured is defined as a child (children) under age 19 who does not have creditable health insurance coverage as described at 42 CFR 457.10 and 45 CFR 146.113 that minimally provides coverage for physician’s services and hospitalization. The six month look back applies. To be eligible for SCHIP 1, the child must be uninsured. • Uninsured children are children under age 19 who do not have creditable health insurance coverage as described at 42 CFR 457.10 and 45 CFR 146.113. A child covered by health insurance at the time eligibility is determined is ineligible unless the insurance is already paid for by Missouri’s Health Insurance Premium Payment Program (HIPP). If the health insurance is dropped without good cause or the child does not have a special healthcare needs exception, the child is ineligible for six months from the month coverage ended. • The six month look back period refers to the six months prior to application. If an uninsured child lost or dropped insurance coverage in the six months prior to application, FSD explores if the reason the child is uninsured meets a good cause reason or if the child meets a special healthcare exception. • Good cause is defined as loss of insurance coverage resulting from no action taken by the insured. Good cause reasons are: • A parent's or guardian's loss of employment due to factors other than voluntary termination; • A parent's or guardian's employment with a new employer that does not provide an option for dependent coverage; • Expiration of a parent's or guardian's dependent Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage period;

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 15B - • Lapse of a child's (children's) health insurance when maintained by an individual other than custodial parent or guardian; • Lapse of a child's (children's) health insurance when the lifetime maximum benefits under their private health insurance have been exhausted; • Lapse of a child's (children's) health insurance when the health insurance plan does not cover an eligible child's preexisting condition; or • Discontinuance of Health Insurance Premium Payment (HIPP). • For children in families with gross income above 225% of the FPL there is a 30 day waiting period from the date of application for coverage. The 30 day waiting period does not apply to children and families with gross income below 225% FPL. These children under 225% of the FPL shall not be subject to the 30-day waiting period as long as the children meet all other qualifications for eligibility. • Any child identified as having special health care needs, defined as a condition which left untreated would result in the death or serious physical injury of a child, that does not have access to affordable employer- subsidized health care insurance will be exempt from the requirement to be without health care coverage for six months in order to be eligible for services, and the 30-day waiting period as long as the child meets all other qualifications for eligibility. Special healthcare needs are established based on a written statement from the child’s treating physician. • Children with special healthcare needs must still be uninsured to qualify and cannot have access to affordable health insurance. Access to affordable insurance available through employment, a group membership, or from a private company causes ineligibility. The affordability guidelines are: • Three percent of 150% of the FPL for a family of three, for families with a gross income of more than 150% and up to 185% FPL. • Four percent of 185% of the FPL for a family of three, for families with a gross income of more than 185% and up to 225% FPL. • Five percent of 225% of the FPL for a family of three, for families with a gross income of more than 225% but less than 300% FPL. • Children in families with gross income above 150% of the FPL cannot have access to affordable employer sponsored or private health insurance. These children must pay a premium to be eligible (a cost sharing provision). The following is a description of the affordability test: • Three percent of 150% of the FPL for a family of three, for families with a gross income of more than 150% and up to 185% FPL. • Four percent of 185% of the FPL for a family of three, for families with a gross income of more than 185% and up to 225% FPL. • Five percent of 225% of the FPL for a family of three, for families with a gross income of more than 225% but less than 300% FPL.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 15C - Continuing Enrollment: Once determined eligible, the children remain eligible until FSD determines they are no longer eligible. Their coverage does not automatically end at 12 months. FSD performs annual reinvestigations to determine continued eligibility. Families are required to report changes in circumstances (i.e., family size, income) within 10 days of when the change occurred. A reinvestigation is a re- determination of continued eligibility. The family completes an IM-1U, “Missouri MC+ Review” or a FA402, "Family Medical Assistance" reinvestigation form as part of the reinvestigation process. This form asks for names of all household members, address, income, and insurance information. It also asks about citizenship and immigration status and net worth. The family is required to respond to the questions asked on the form and submit current income verification. Upon receipt of the form, FSD will determine if additional information is needed to complete the review based on claimant’s responses. If so, FSD makes a written request for the information and allows at least 10 days for a response. When a change is reported to the FSD, the Eligibility Specialist makes a determination of continued eligibility and notifies the family in writing when a decision is made. SCHIP 1 and SCHIP 2 cases are closed following a notice to the family if the family fails to complete an annual reinvestigation. A complete review of eligibility is conducted annually. In Missouri, reinvestigation means the same as re-determination. The family is not required to re-apply. However, an annual reinvestigation is required. A significant difference between an application for MO HealthNet and a reinvestigation for MO HealthNet is the amount of documentation required. Applicants are required to submit verification of citizenship and SSN documentation for individuals who are applying. Citizenship and SSNs are not re-verified for those same individuals during a reinvestigation. A copy of the form used for MO HealthNet reinvestigations is attached.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 16 - Premium Collection and Reinstatement Process: For children ages birth through age 18 with family income between 150% and 300% FPL, the premiums are detailed in the premium chart. Please see Attachment 3. Annual Reinvestigations: The notification and hearing process followed for SCHIP 1 and SCHIP 2 is the same as for all MO HealthNet recipients. Reinvestigations are conducted annually. The reinvestigation process begins by mailing the family a two-page reinvestigation form to complete and return. The form asks the family to list:  Mailing address;  All children, parents/guardians and stepparents who live in the home and their Social Security Numbers, citizenship or immigration status;  Information about employment, child care costs, other income, net worth, health insurance coverage, and absent parent information. Eligibility continues while the reinvestigation process is being completed. If a point of ineligibility is discovered, the family is notified and given an opportunity to request a hearing. The notification and hearing process followed for SCHIP 1 and SCHIP 2 is the same as for all MO HealthNet recipients. 4.3.1 Describe the State’s policies governing enrollment caps and waiting lists (if any) (Section 2106(b)(7)) (42 CFR 457.305(b))  Check here if this section does not apply to your state. 4.4 Describe the procedures that assure that: 4.4.1 Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42 CFR 457.350(a)(1)) 457.80(c)(3)) Response: FSD uses the same application for MO HealthNet, SCHIP 1, and SCHIP 2. The same Eligibility Specialist makes the eligibility determination for MO HealthNet, SCHIP 1, and SCHIP 2. Children are determined ineligible for regular MO HealthNet before being approved for SCHIP 1 or SCHIP 2. The application form asks about health insurance the family has and whether or not they have access to insurance.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 17 - 4.4.2 The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42 CFR 457.350(a)(2)) Response: FSD uses the same application for, SCHIP 1, and SCHIP 2. The same Eligibility Specialist makes the eligibility determination for MO HealthNet, SCHIP 1, and SCHIP 2. Children are determined ineligible for regular MO HealthNet before being approved for SCHIP 1 or SCHIP 2. 4.4.3 The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42 CFR 431.636(b)(4)) Response: FSD uses the same application for, SCHIP 1, and SCHIP 2. The same Eligibility Specialist makes the eligibility determination for MO HealthNet, SCHIP 1, and SCHIP 2. Children are determined ineligible for regular MO HealthNet before being approved for SCHIP 1 or SCHIP 2. 4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42 CFR 457.805) (42 CFR 457.810(a)-(c)) 4.4.4.1  Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. Response: There is a six month look back period for health insurance when determining eligibility. Children whose available health insurance coverage was dropped within the last six months without good cause will have a six month waiting period for SCHIP 1 coverage. The six month look back period does not apply to children in families with income below 150% FPL. 4.4.4.2  Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 18 - Response: Crowd-out will be monitored by comparing the increase in MO HealthNet enrollment concurrent with the decrease in private insurance enrollment. The State of Missouri has implemented several safeguards against crowd-out, including a six-month waiting period and cost-sharing requirements. The application process for Missouri also has a number of other crowd-out deterrents built in. Although Missouri has taken several steps to simplify the application process by reducing the size of its application and accepting applications in the mail, it has also built more steps into the verification process than many states use to ensure that only applications from eligible individuals are accepted. For example, Missouri requires applicants with income between 150% and 300% of FPL to obtain two quotes from private insurers as proof that affordable insurance alternatives do not exist. In addition, children with incomes between 226% and 300% of FPL have a six-month penalty applied if they fail to pay required SCHIP 1 premiums and are not eligible for coverage until the six months expire. This penalty provision does not apply to those children between 150% and 225% of FPL who may fail to pay a required premium. There is a six-month waiting period for children who drop insurance without good cause, except for children with special health care needs. Children in families with income above 150% of FPL are not eligible if they have access to affordable insurance. In addition, families with income above 225% FPL have a 30 day waiting period before eligibility begins. In addition to monitoring the increase in MO HealthNet enrollment and the decrease in private insurance enrollment, the State will use data and information from several sources to further analyze whether the availability of SCHIP is the causative agent in the reduction of private insurance enrollment. Because the vast majority of private insurance, particularly for children, is employer-sponsored insurance the State will focus its analysis in this area. These additional data provide additional information about the number of business providing private health insurance to employees, the cost of such insurance to employees, the take- up rate of private employer-sponsored health insurance, and the labor market. The data are both national level and Missouri specific. Analysis of these data will allow the

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 18A - State to better assess whether the availability of SCHIP or whether market factors effecting the availability and cost of private insurance are the causative agent(s) in any reduction in private insurance enrollment and any increase in SCHIP enrollment. The following data sources will be utilized: • The Medical Expenditure Panel Survey (MEPS) Insurance Component. Data are available by state; as of July 11, 2007 Missouri specific data are available for the years 1996 – 2004. • Data from the annual “Employer Health Benefits Survey” conducted by the Kaiser Family Foundation and the Health Research and Education Trust (HRET). The data are national only; as of July 11, 2007, the most recent survey results available were from 2006. • State and Area Employment, Hours and Earnings data from the U.S. Department of Labor, Bureau of Labor Statistics (BLS). BLS data, are collected each month; as of July 11, 2007, the most recent data are from May 2007. In addition to using data, the State will augment its analysis through the use of recently published research and studies in the area of substitution and crowd-out. 4.4.4.3  Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution. Response: Refer to response in section 4.4.4.2. 4.4.4.4  If the State provides coverage under a premium assistance program, describe: The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period. The minimum employer contribution.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 19 - The cost-effectiveness determination. 4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

Response: CMS officials have held that Missouri has no federally-recognized American Indian/Native American tribes within the state, and, therefore, Missouri has no specific obligations pursuant to 42 CFR § 457. The fact that Missouri has no federally-recognized American Indian/Native American tribes was affirmed by the CMS Region VII office as recently as May 2007. • The Eastern Shawnee Tribe of Oklahoma tribe is not associated with Missouri in the Federal Register’s “Indian Entities Recognized and Eligible To Receive Services From the United States Bureau of Indian Affairs” (Vol. 72, No. 55 / Thursday, March 22, 2007). • The Eastern Shawnee Tribe of Oklahoma (http://www.easternshawnee.org/index.html and http://www.eighttribes.org/eastern-shawnee/) listed above is actually centered on the Oklahoma/Missouri border. • Article II of the Constitution of the Eastern Shawnee Tribe (http://thorpe.ou.edu/constitution/eastshawcons.html) states that “...Eastern Shawnee lands, which are located in the north east section of the State of Oklahoma, and such other territory as may hereafter be added thereto.” This evidence is fully consistent with the CMS' position that Missouri has no federally-recognized American Indian/Native American tribes within the state. Recognizing that a member of a tribe may re-locate to the State, Missouri will exempt children who are members of federally-recognized tribes from cost- sharing requirements as stipulated in Section 2103(e)(1)(A). Children who identify themselves as American Indian or Native Alaskan on the SCHIP application will be notified that, upon receipt of documentation of tribal membership, they will no longer be required to submit monthly premiums. Any premiums paid will be reimbursed within 45 days of receipt of documentation of tribal membership. The materials sent to all new enrollees will include information on the cost-sharing exemption for members of federally-recognized American Indian or Native Alaskan tribes to ensure that

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 19A - those not indicating race on the application will be notified of this exemption.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 20 - Section 5. Outreach (Section 2102(c)) 5.1 (formally 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42 CFR 457.80(b)) 5.1.1 (formally 2.2.1) The steps the State is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance): Response: Outreach and eligibility determination for MO HealthNet occurs throughout Missouri with State offices in every county. Free materials are available and used by other entities assisting in outreach, such as other State agencies with which Department of Social Services (DSS) has interagency agreements, social welfare organizations, schools, and health care providers through outstationed Eligibility Specialists. Through the interagency agreement between the DSS and the Department of Health and Senior Services (DHSS), a Well Child Outreach Project and a Lead Poisoning Outreach Program have been developed and implemented and outreach activities are conducted to identify possible MO HealthNet eligibles and refer them to the Family Support Division (FSD) for eligibility determination.The State will have a simplified mail-in application process. This should overcome the burden of applying in person at an FSD office. There is an application on the DSS website at http://www.dss.mo.gov/mhk/appl.htm that can be printed, completed, and mailed in, or completed online.Applications are also available at hospitals, local public health agencies, mental health facilities, and schools. Individuals can call a toll- free number in Missouri to request that an application be mailed to them or they can call their local FSD office to request an application be mailed. Missouri will continue to outstation Eligibility Specialists at hospitals and federally qualified health centers. The State will explore the effectiveness of expanding the sites for enrolling children in a wider variety of community settings with the Managed Care Consumer Advisory Committee, advocates for children, and health care providers. 5.1.2 (formally 2.2.2) The steps the State is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership: Response: The State cooperates fully with the privately funded Caring Foundation for Children in making referrals and receiving referrals so that there is coordination with MO HealthNet and maximum outreach for both programs. The MO HealthNet Statewide Coalition, which was formally funded by Missouri’s Covering Kids and Families grant from The Robert Wood Johnson Foundation, continues to provide outreach. Due to the large number

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 20A - of organizations that assist in outreach, Missouri continues to rely on them to be our voice in the community. The Missouri Primary Care Association is the lead agency for the grant. 5.2 (formally 2.3) Describe the procedures the State uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42 CFR 457.80(c)) Response: Outreach assistance through schools/agencies/organizations working with eligible families is the primary outreach tool utilized by the MO HealthNet Statewide Coalition. These partners educate families and distribute materials developed and produced through the Covering Kids and Families grant. Prior to the grant funding ending, the Coalition used the grant to produce and distribute printed materials. In 2006, more than 180,000 fliers and 9,000 posters were distributed. While the funding ended, the Coalition continues to provide outreach and holds quarterly meetings to share information and strategize. Coalition members help educate families and distribute outreach materials. Outreach and eligibility determination activities to increase the number of children with creditable coverage occur throughout Missouri with State offices in every county. The State uses brochures and informational flyers to educate families about the health coverage available through the MO HealthNet Division. Missouri stresses that:  Children do not have to be on TANF (cash assistance) to be MO HealthNet eligible;  Children may receive MO HealthNet benefits even if both parents live in the home; and  One or both parents can work full-time and the children may still be MO HealthNet eligible. Information about MO HealthNet is shared with families through the press, public speaking opportunities of executive agency staff, public service announcements, and Managed Care Organizations (MCOs). The State involves the Managed Care Consumer Advisory Committee and coordinates with the FSD, the DHSS, school districts, and other appropriate agencies or groups to include public health insurance programs in the design and implementation of the brochures, flyers, and other education material. Missouri continues to identify barriers to MO HealthNet enrollment by receiving information about those barriers from schools, hospitals, and local public health agencies through regularly scheduled

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 20B - interagency meetings, provider association contacts, and the Managed Care Consumer Advisory Committee. Missouri continues to outstation Eligibility Specialists at some hospitals and federally qualified health centers. Missouri continues agreements that allow federally qualified health centers and local public health agencies to accept applications on behalf of the FSD. The State will explore the effectiveness of expanding the sites for enrolling children in a wider variety of community settings with the Managed Care Consumer Advisory Committee, advocates for children, and health care providers. The State will also be cooperating with the Missouri Hospital Association in their efforts to develop an effective outreach program for MO HealthNet children. We will also partner with local community groups and agencies which want to sponsor local outreach initiatives. Income will be determined by looking at the total gross income available to the children for whom the application is being made. The current assistance group definitions used by Missouri for MO HealthNet budgeting will be followed. A standard income disregard equal to 100% of the FPL will be made from the gross income figure. The net income figure will be compared to 200% of FPL to determine if the child(ren) is (are) eligible. To be eligible, this net figure must not exceed 200% of FPL for children. There are no other disregards for SCHIP 1 children. An assistance group is comprised of the child for whom benefits are being requested and his or her biological or adoptive parents if living together in the same household. It is important to note that the State is concerned that SCHIP 1 does not “crowd out” private insurance options. The following measures will help address crowd out of private insurance options: • There will be a six month look back period for health insurance when determining eligibility. Children whose parents’ available private health insurance coverage was dropped within the last six months will have a six month waiting period under SCHIP 1. Uninsured is defined as a child (children) under age 19 who does not have creditable health insurance coverage as described at 42 CFR 457.10 and 45 CFR 146.113 that minimally provides coverage for physician’s services and hospitalization. The six month look back applies. To be eligible for SCHIP 1, the child must be uninsured. • Uninsured children are children under age 19 who do not have creditable health insurance coverage as described at 42 CFR 457.10 and 45 CFR 146.113. A child covered by health insurance at the time eligibility is determined is ineligible unless the insurance is already paid for by Missouri’s Health Insurance Premium Payment Program (HIPP). If the health insurance is dropped without good cause or the child does not have a special healthcare needs exception, the child is ineligible for six

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 20C - • months from the month coverage ended. • The six month look back period refers to the six months prior to application. If an uninsured child lost or dropped insurance coverage in the six months prior to application, FSD explores if the reason the child is uninsured meets a good cause reason or if the child meets a special healthcare exception. • Good cause is defined as loss of insurance coverage resulting from no action taken by the insured. Good cause reasons are: • A parent's or guardian's loss of employment due to factors other than voluntary termination; • A parent's or guardian's employment with a new employer that does not provide an option for dependent coverage; • Expiration of a parent's or guardian's dependent Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage period; • Lapse of a child's (children's) health insurance when maintained by an individual other than custodial parent or guardian; • Lapse of a child's (children's) health insurance when the lifetime maximum benefits under their private health insurance have been exhausted; • Lapse of a child's (children's) health insurance when the health insurance plan does not cover an eligible child's preexisting condition; or • Discontinuance of Health Insurance Premium Payment. • For children in families with gross income above 225% of the FPL there is a 30 day waiting period from the date of application for coverage. The 30 day waiting period does not apply to children and families with gross income below 225% FPL. These children under 225% of the FPL shall not be subject to the 30-day waiting period as long as the children meet all other qualifications for eligibility. • Any child identified as having special health care needs, defined as a condition which left untreated would result in the death or serious physical injury of a child, that does not have access to affordable employer-subsidized health care insurance will be exempt from the requirement to be without health care coverage for six months in order to be eligible for services, and the 30-day waiting period as long as the child meets all other qualifications for eligibility. Special healthcare needs are established based on a written statement from the child’s treating physician. • Children with special healthcare needs must still be uninsured to qualify and cannot have access to affordable health insurance. Access to affordable insurance available through employment, a group membership, or from a private company causes ineligibility. The affordability guidelines are • Three percent of 150% of the FPL for a family of three, for families with a gross income of more than 150% and up to 185% FPL. • Four percent of 185% of the FPL for a family of three, for families with a gross income of more than 185% and up to 225% FPL. • Five percent of 225% of the FPL for a family of three, for families with a gross income of more than 225% but less than 300% FPL.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 20D -

• Children in families with gross income above 150% of the FPL cannot have access to affordable employer sponsored or private health insurance. These children must pay a premium to be eligible (a cost sharing provision). The following is a description of the affordability test: • Three percent of 150% of the FPL for a family of three, for families with a gross income of more than 150% and up to 185% FPL • Four percent of 185% of the FPL for a family of three, for families with a gross income of more than 185% and up to 225% FPL • Five percent of 225% of the FPL for a family of three, for families with a gross income of more than 225% but less than 300% FPL. Non-Emergency Medical Transportation  Children in families with gross income below 150% will be covered. Service(s) furnished or proposed to be furnished that is (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 recipient’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.  Children in families with gross income between 150% through 300% will not be covered. This benefit is so unheard of in any health insurance plan that its inclusion would serve as a significant incentive for the dropping of private coverage. Crowd out will be evaluated yearly to determine if additional protections are warranted. If crowd out does become a problem the State will develop additional anti-crowd out measures as warranted by the scope and nature of the problem. Additional options may include:  Adding an insurance availability test to preclude participation  Lengthening the look back period;  Implementing cost sharing provisions;  Moving to once yearly open enrollment periods for children with family income over 200% of gross FPL;  Other measures designed to efficiently deal with what the research finds.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 21 -

5.2-ELThe State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP.

5.3 Strategies Describe the procedures used by the State to accomplish: Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42 CFR 457.90) Response: Missouri will use brochures and informational flyers to educate families about the health coverage available through MO HealthNet, SCHIP 1, and SCHIP 2. We will stress that:  Children do not have to be on TANF (cash assistance) to be MO HealthNet eligible;  Children may receive MO HealthNet benefits even if both parents live in the home; and  One or both parents can work full-time and the children may still be MO HealthNet eligible. Outreach Plan: The outreach plan has five major components:  Statewide public information campaign  Expanded training  Improved case-specific problem resolution  Systems changes; and  Support for regional and local initiatives, including the outstationing of eligibility workers. The outreach program for SCHIP 1 and SCHIP 2 will continue to complement and build upon current MO HealthNet outreach initiatives. Through the outreach plan Missouri will ensure that all uninsured families in Missouri are aware of the health care coverage that is available to them. As a result, Missouri expects to enroll eligible families into MO HealthNet, SCHIP 1 and SCHIP 2. Outreach assistance through schools/agencies/organizations working with eligible families is the primary outreach tool utilized by the MO HealthNet Statewide Coalition. These partners educate families and distribute materials developed and produced through the Covering Kids and Families grant. Prior to the grant funding ending, the Coalition used the grant to produce and distribute printed materials. In 2006, more than 180,000 fliers and 9,000 posters were distributed.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 -21A- While the funding ended, the Coalition continues to provide and hold quarterly meetings to share information and strategize. Coalition members help educate families and distribute outreach materials. Missouri has not targeted outreach to any specific populations. However, the MO HealthNet Statewide Coalition translated their 2006 materials into Spanish. Missouri will involve the Managed Care Consumer Advisory Committee, the FSD staff, the DHSS, school districts, and other appropriate agencies or groups in the design and implementation of the brochures and flyers. Missouri will continue to coordinate eligibility outreach efforts with schools, hospitals, and local public health agencies by identifying barriers to MO HealthNet enrollment. FSD allows individuals to make application in hospitals, federally qualified health centers, and some local public health agencies. FSD Eligibility Specialists are located in some of these locations. In other locales applicants receive assistance from facility staff that have been trained on the application process by FSD. The FSD policy manual delineates the application process and program requirements. FSD staff receive training on the rules and eligibility requirements and application procedures. The manual is updated by Income Maintenance Memoranda on an as-needed basis. The Phone Center is centralized in one FSD county office. Phone center staff can be reached Monday through Friday, 8:00 am to 5:00 pm by calling 1-888-275-5908. A voice mail system is in place for incoming calls received after regular business hours. The Phone Center is staffed by experienced Eligibility Specialists whose duties include:  Answering phone inquiries;  Accepting and processing applications;  Making referrals;  Mailing applications;  Processing Breast and Cervical Cancer Treatment applications mailed to the center by Show Me Healthy Women providers; and  Processing presumptive eligibility applications mailed to the center by designated providers.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 22 - Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103) □ Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7. 6.1 The State elects to provide the following forms of coverage to children: (Check all that apply.) (42 CFR 457.410(a)) 6.1.1 □ Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1 □ FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2 □ State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3 □ HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.2 □ Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430). Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions. 6.1.3 □ Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage. 6.1.4  Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1 □ Coverage the same as Medicaid State plan 6.1.4.2 □ Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 23 - 6.1.4.3 □ Coverage that either includes the full EPSDT benefit or that the State has extended to the entire Medicaid population 6.1.4.4 □ Coverage that includes benchmark coverage plus additional coverage 6.1.4.5 □ Coverage that is the same as defined by existing comprehensive state- based coverage 6.1.4.6 □ Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7  Other (Describe) Response: Except for NEMT, Missouri will provide the identical package of covered services to SCHIP 1 and SCHIP 2 recipients as is currently provided to MO HealthNet recipients under Title XIX. NEMT is not covered for children in families with income more than 150% FPL. 6.2 The State elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42 CFR 457.490) Response: The services checked below are generally covered for MO HealthNet categorically needy eligibles and would be covered for SCHIP 1 and SCHIP 2, depending on the need of the recipient. All these services are subject to the same limitations and prior approvals as they are in the approved MO HealthNet State Plan. Please see Attachments 9 and 9a. The following specific services are found in the MO HealthNet State Plan Amendment: • Over the Counter Medicine – Section 3.1-A, page 15aa. • Outpatient Mental Health Services – Section 3.1-A, page 1. Although outpatient mental health services are not delineated, they are a covered service under Missouri's State Plan Amendment. • Dental Services - Section 3.1-A, pages 10f and 18d. • Outpatient Substance Abuse Treatment and Outpatient Substance Abuse Treatment Services - Section 3.1-A, page 17aaa.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 23A - • Care Coordination - Section 3.1-A, pages 1a-1 and 1a-2, 1b-1 to 1b-3, 1c to 7c, 1f to 5f, and 1g to 10g. The State of Missouri uses the terms Case Management and Care Coordination interchangeably. • Rehabilitative Services - Section 3.1-A, page 17.

The MO HealthNet Program rules include, but are not limited to, benefit limits, extension of benefit limit procedures, prior authorization requirements, and age limits for services. 6.2.1  Inpatient services (Section 2110(a)(1)) 6.2.2  Outpatient services (Section 2110(a)(2)) 6.2.3  Physician services (Section 2110(a)(3)) 6.2.4  Surgical services (Section 2110(a)(4)) 6.2.5  Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 24 - 6.2.6  Prescription drugs (Section 2110(a)(6)) 6.2.7  Over-the-counter medications (Section 2110(a)(7)) 6.2.8  Laboratory and radiological services (Section 2110(a)(8)) 6.2.9  Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9)) 6.2.10  Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11  Outpatient mental health services, other than services described in 6.2.19., but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.12  Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13  Disposable medical supplies (Section 2110(a)(13)) 6.2.14  Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15  Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16  Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17  Dental services (Section 2110(a)(17)) 6.2.18  Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19  Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20  Case management services (Section 2110(a)(20)) 6.2.21  Care coordination services (Section 2110(a)(21)) 6.2.22  Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23  Hospice care (Section 2110(a)(23)) 6.2.24  Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25  Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26  Medical transportation (Section 2110(a)(26)) Response: NEMT is not covered for children in families with income above 150% FPL. Emergency ambulance services are covered for a recipient whose life or health is in danger. NEMT is covered for children in families with income of and less than 150% FPL.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 25 - 6.2.27 □ Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28 □ Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28)) 6.3 The State assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42 CFR 457.480) 6.3.1  The State shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2 □ The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6 6.4 Additional Purchase Options. If the State wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the State must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010) 6.4.1 □ Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the State to administer the plan, if it demonstrates the following (42 CFR 457.1005(a))

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 26B -

6.4.1.1 Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The State may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42 CFR 457.1005(b)) 6.4.1.2 The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42 CFR 457.1005(b)) 6.4.1.3 The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42 CFR 457.1005(a)) 6.4.2  Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42 CFR 457.1010) 6.4.2.1 Purchase of family coverage is cost-effective relative to the amounts that the State would have

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date: Bolded/Italics Added Information Prior Approval Date: 09/28/2007 Strikethrough Deleted Information - 27 - paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42 CFR 457.1010(a)) Response: The Health Insurance Premium Payment (HIPP) Program is a MO HealthNet Program that pays for the cost of health insurance premiums, coinsurance, deductibles, and copayments for certain MO HealthNet participants. The program purchases health insurance for MO HealthNet eligible persons when it is determined cost effective. Similarly, the HIPP Program purchases health insurance for MO HealthNet For Kids eligible children when it is determined the health insurance does not meet the affordability test, but is found to be cost effective. Cost effective means that it costs less to buy the health insurance to cover medical care than to pay for the same services with MO HealthNet funds. When determining the cost effectiveness of a health insurance plan, the following data is considered: the cost of the insurance premium, coinsurance and deductible; the scope of services covered, the average anticipant MO HealthNet utilization by age, sex, geographic location and coverage group, and annual administrative expenditures. The analysis is based on the data of the MO HealthNet participants enrolled in the insurance plan. The average MO HealthNet expenditures are based upon a peer grouping consisting of age, sex, coverage group and county from the previous year. If the cost of the insurance premiums and cost sharing for the insurance plan is likely to be less than the average MO HealthNet expenditures, the policy is considered to be cost effective. See Attachment 12 for a specific example. The HIPP Program cannot find health insurance policies for MO HealthNet recipients, rather it purchases policies already available to recipients through employers, former employers, labor

Missouri Application for the State Children’s Health Insurance Program Proposed Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 27A - unions, credit unions, church affiliations, other organizations, or individual policies. The HIPP Program is the same program the State currently uses. There have been no changes implemented in the HIPP Program. The State will provide employer-sponsored insurance (ESI)/HIPP coverage for the SCHIP 2 children and those in the SCHIP 1 program when it is determined to be cost effective. When a HIPP application is received the information is verified by contacting the employer for group policies or the insurance company if it is an individual policy. It is necessary to verify the amount of the premium, how often it will be paid, and whether the premium is payroll deducted or paid directly to employer or insurance company. The benefit package is reviewed for deductibles, copays, and coinsurance amounts that the policyholder would be responsible for. The effective date of the policy and the claims address are verified by contacting the insurance company. The application is then processed in the HIPP system to determine cost effectiveness of the policy and the policy holder is notified of the determination by letter. The HIPP application is processed in the HIPP system to determine cost effectiveness of the policy by entering the peer grouping information into the system. The peer grouping information includes age, gender, Medical Eligibility Code (ME Code), county code, and the coverage code for the policy. The system determines the average cost of healthcare that was expended in the previous year for each Medicaid recipient in that group. The system then compares that information with the Group Health Plan costs which includes the annual premium amount, annual policy deductibles, and annual coinsurance amounts. As part of the HIPP application process, the HIPP system compares the services provided under the Group Health Plan, including exclusions for pre-

Missouri Application for the State Children’s Health Insurance Program Proposed Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 27B - existing conditions and exclusions to enrollment and lifetime maximum benefits imposed, with the services to which the individual is entitled under the MO HealthNet Program. Coverage of services not provided under the Group Health Plan, but to which the individual is entitled under the MO HealthNet Program, are provided under MO HealthNet as wrap-around services. 6.4.2.2 The State assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42 CFR 457.1010(b)) 6.4.2.3 The State assures that the coverage for the family otherwise meets title XXI requirements. (42 CFR 457.1010(c))

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 28 - Section 7. Quality and Appropriateness of Care □ Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8. 7.1 Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42 CFR 457.495(a)) Will the State utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1  Quality standards 7.1.2  Performance measurement 7.1.3 □ Information strategies 7.1.4  Quality improvement strategies Response: SCHIP 1 and SCHIP 2 is not a MO HealthNet entitlement but it will be implemented as a MO HealthNet look-alike program. SCHIP 1 and SCHIP 2 will use MO HealthNet's comprehensive benefit package, with the exception of not providing NEMT for children in families with income above 150% FPL, MO HealthNet Managed Care, and the Fee-For-Service delivery system, all quality and appropriateness of care measures, and grievance procedures. In keeping with federal and state regulations, the MCOs must meet program standards for monitoring and evaluating systems as outlined in the MO HealthNet Managed Care contract. Each MCO must implement a Quality Improvement (QI) strategy that addresses the standards as noted but is not limited to the requirements within the MO HealthNet Managed Care QI Strategy or the MO HealthNet Managed Care contract. The MCOs provide the State with regular reports of utilization and quality assessment including special needs; lead poisoning prevention; member grievances and appeals; provider complaints; grievances and appeals; and fraud and abuse detection. An annual evaluation contains information related to utilization and clinical performance, accessibility standards, quality indicators, performance improvement projects, care management, and subcontractor oversight. Performance measures are reported in accordance with Health Plan Employer Data and Information Set (HEDIS) specifications. The required HEDIS measures are outlined in the QI Strategy. Please see Attachment 4. The DHSS grants access to Missouri Health Strategic Architectures and Information Cooperative (MOHSAIC), DHSS' integrated public health information system, to public health staff, health care providers, and others who have a legal right to the information to better provide care and services. DHSS is responsible

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 29 - for assuring the confidentiality of data and information. Access to data is granted in accordance with state and federal laws. Access is limited to data needed to fulfill the requestor's responsibilities and/or to provide services. The MOHSAIC system is utilized by the MO HealthNet Fee-For-Service and MO HealthNet Managed Care Programs. The DHSS also monitors services provided to members with special health care needs. External monitoring includes an annual, external quality review of the MCOs by an external quality review organization. The review is comprised of a compliance review analysis, encounter data validation, medical record review, and validation of MCO performance improvement projects and measures. An external, annual evaluation will be conducted on SCHIP 1 and SCHIP 2. The evaluation is for the collection and analysis of information about SCHIP 1 and SCHIP 2 to study the impact of state agency policy decisions about the SCHIP 1 and SCHIP 2 on the enrollees in the program and on program participation by the uninsured. 7.2 Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42 CFR 457.495) 7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations (Section 2102(a)(7)) (42 CFR 457.495(a)) Response: The delivery systems described below apply to MO HealthNet, SCHIP 1, and SCHIP 2. MO HealthNet Fee-For-Service Delivery System The MO HealthNet Division continues to identify barriers and develop strategies that guarantee maximum screening of Early Periodic Screening, Diagnosis, and Treatment (EPSDT) eligible children under both MO HealthNet Fee-For-Service and MO HealthNet Managed Care. The MO HealthNet Division continues to collaborate with other state and local agencies to identify problem areas that affect the screening and health care of children. Activities to increase awareness of the importance of preventative health screenings include, but are not limited to, the following:

 The MO HealthNet Division continues to provide brochures regarding available EPSDT services. Missouri FSD county offices, and any other

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 30 - entity requesting supplies, distribute the EPSDT brochures. Please see Attachment 5.  Reminder letters are sent to each child on or shortly after they become age appropriate for a health screen according to the periodicity schedule. Please see Attachment 6.  The MO HealthNet Division allows providers to use electronic record keeping of the ESPDT screening components instead of the paper screening forms.  The MO HealthNet Division held meetings with health care providers and other state agencies to review and revise the EPSDT screening forms. The MO HealthNet Division continues outreach efforts in conjunction with DHSS through a cooperative agreement. Collaboration between the two agencies consists of: • Local public health agencies continue to view and download county-specific EPSDT reports each month for outreach and follow-up. The EPSDT reports are available electronically. • Participation in initiatives of DHSS that support well child issues—Folic Acid Advisory Group and the Crosswalk Team. • Initiate collaborative meetings in conjunction with the SCHIP 1 and SCHIP 2. This statewide effort brings together local public health agencies and schools to enhance outreach efforts to families of children eligible for SCHIP 1 and SCHIP 2. • Well child care (including Health Children and Youth (HCY) exams) information about SCHIP 1 and SCHIP 2 is available on the DHSS website, Baby Your Baby pages: http://www.dhss.mo.gov/babyyourbaby/. MO HealthNet Managed Care Delivery System The contract with the MCOs include service accessibility standards for 24-hour coverage, travel distance standards, appointment standards, and care management. The monitoring of the standards is further outlined in the QI Strategy. The HEDIS measures in the QI Strategy include childhood immunizations, well child visits, adolescent well child visits, and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. The State continues to include language in the MO HealthNet Managed Care contracts tying EPSDT performance to capitation payments.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 31 - 7.2.2 Access to covered services, including emergency services as defined in 42 CFR part 457.10. (Section 2102(a)(7)) 42 CFR 457.495(b)) Response: The comprehensive benefit package for SCHIP 1 and SCHIP 2 includes emergency medical/mental health services. The contract with the MCOs include service accessibility standards for 24-hour coverage, prior authorization, travel distance standards, appointment standards, and care management. The monitoring of the standards is further outlined in the QI Strategy. 7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42 CFR 457.495(c)) Response: The delivery systems described below apply to MO HealthNet, SCHIP 1, and SCHIP 2.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 32 - MO HealthNet Managed Care Delivery System The contract with the MCOs include service accessibility standards for 24- hour coverage, prior authorization, travel distance standards, appointment standards, and care management. The monitoring of the standards is further outlined in the QI Strategy. In addition, the MCO shall have established written policies and procedures concerning: • How a member may obtain a referral to an out-of-network provider when the MCO does not have a health care provider with appropriate training or experience in the network to meet the particular health care needs of the member; • How a member, with a condition which requires on-going care from a specialist, may request a standing referral to such a specialist; and • How a member, with a life-threatening condition or disease, either of which requires a specialized medical care over a prolonged period of time, may request and obtain access to a specialty care center. The MCO must provide adequate access to physician specialists for PCP referrals and employ or contract with physician specialists in sufficient numbers to ensure specialty services can be made available in a timely manner. The MCO shall have protocols for coordinating care between PCPs and specialists which include the expected response time for consults between PCPs and specialists. 7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42 CFR 457.495(d)) Response MO HealthNet Fee-For-Service Delivery System

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 33 - Under the MO HealthNet Program, certain covered services and equipment require approval from the DSS, MO HealthNet Division, prior to provision of the service as a condition of reimbursement. Prior authorization is used to promote the most effective and appropriate use of available services and to determine in conjunction with the ordering provider, the medical necessity of the service. Providers are required to seek prior authorization for certain specified services before delivery of the services. In addition to services that are available through the traditional MO HealthNet Program, expanded services are available to children 20 years of age and under through the Healthy Children and Youth (HCY) Program. Some expanded services also require prior authorization. Certain services require prior authorization only when provided in a specific place or when they exceed certain limits. The Pharmacy and Clinical Services Unit of the MO HealthNet Division operates a toll-free hotline for providers to request overrides on drug products with restricted access due to clinical or fiscal edits and prior authorization. The hot- line staff operate an internet web portal-based system to process requests for drug products, which have been denied through the point-of-service claims processing system. The Unit is also responsible for responding to requests through the Exception Process for essential medical items or services, including insulin pumps and supplies, which are not typically reimbursed through the MO HealthNet Program. The MCOs have written policies and procedures for prior authorization of non- emergency services and the time frames in which authorizations will be processed (approved or denied) and providers and members are notified. The policies and procedures include the requirement to not exceed 14 calendar days following the receipt of the request of service to provide approval or denial. MO HealthNet Managed Care Delivery System 7.2.5 The MCOs have written policies and procedures for prior authorization of non- emergency services and the time frames in which authorizations will be processed (approved or denied) and providers and members are notified. The policies and procedures include the requirement to not exceed 14 calendar days following the receipt of the request of service to provide approval or denial

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 34 - Section 8. Cost Sharing and Payment (Section 2103(e □ Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9. 8.1 Is cost-sharing imposed on any of the children covered under the plan? (42 CFR 457.505) 8.1.1  YES. 8.1.2 □ NO, skip to question 8.8.

8.2 Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c)) 8.2.1 Premiums Response: The premium amounts are calculated according to Missouri State law (the State Fiscal Year Budget and MO Revised Statute Section 208.640). Families of children in SCHIP 1 shall pay the following premium based on family size and income to be eligible to receive services: • Enrollees with incomes above 150 percent of the FPL and up to 185 percent of the FPL shall pay four percent of the difference in income between 150 and 185 percent of the FPL. • Enrollees with incomes above 185 percent of the FPL and up to 225 percent of the FPL shall pay: o four percent of the difference in income between 150 and 185 percent of the FPL; o plus eight percent of the amount of difference in income between 185 percent of the FPL and 225 percent of the FPL. • Enrollees with incomes above 225 percent of the FPL and up to 300 percent of the FPL shall pay: o four percent of the difference in income between 150 and 185 percent of the FPL; o plus eight percent of the amount of difference in income between 185 percent of the FPL and 225 percent of the FPL; o plus 14 percent of the amount of difference in income between 225 and 300 percent of the FPL.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 34A - • In no case shall the family be charged more than 5% of the family's gross income. The premium invoicing system is designed to not invoice a monthly premium in excess of 5% of the family’s gross annual income divided by twelve (12). The following table presents an example of the premium calculation.

8.2.2 Deductibles: Response: None 8.2.3 Coinsurance or copayments: Response: None 8.2.4 Other: Response: None 8.3 Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42 CFR 457.505(b)) Response: The Eligibility Specialist at FSD mails an approval notice to recipients when they are approved for SCHIP 1. The approval notice advises the recipients if they must pay a premium to be eligible for coverage and the premium chart is attached to the approval notice. Following initial approval for coverage, an invoice is mailed to recipients each month billing them for the next month's premium. The monthly invoice also directs recipients to contact their FSD Eligibility Specialist to report any changes in income, family size, or address. The recipient is asked to report such changes within 10 days of receipt of the invoice. The premium chart and information

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 35 - about premiums may also be found on the DSS website and in outreach/educational materials. The premium is based on family size and income to ensure that no family pays more than 5% of their income for coverage. The invoice that is due in July for August health care coverage reflects the new premium amount. The premium chart is updated and mailed to recipients annually each June. The Missouri General Assembly considered and approved a statutory change to allow for the submission of a combination SCHIP State Plan in Senate Bill 577 passed by the 94th Missouri General Assembly on May 18, 2007, and signed by the Governor on July 2, 2007. To ensure public input in Missouri's Separate Children's Health Insurance Program, the MO HealthNet Division conducts quarterly meetings with the following groups.  Managed Care Consumer Advisory Committee  All Plan Meeting  Quality Assessment and Improvement Advisory These meetings are scheduled one year in advance and are open to group members, MO HealthNet Division personnel, and invited guests. These meetings are also open to members of the public. Meeting notices are posted at the State Capitol, the Broadway State Office Building, Department of Social Services offices, the Howerton Building, the Jefferson Building, and on the MO HealthNet Division website at http://www.dss.mo.gov/mhd/. A presentation on the change from a Medicaid expansion to a combination SCHIP program was given at the June 20, 2007 Managed Care Consumer Advisory Committee meeting. A similar presentation will be given at the Quality Assessment and Improvement Advisory group meeting on July 25, 2007, and the All Plan Meeting on July 26, 2007. 8.4 The State assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e)) 8.4.1  Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42 CFR 457.530) 8.4.2  No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42 CFR 457.520) 8.4.3  No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42 CFR 457.515(f))

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 35A - 8.5 Describe how the State will ensure that the annual aggregate cost-sharing for a family does not exceed 5% of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the State for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42 CFR 457.560(b) and 457.505(e)) Response: Premium adjustments are calculated annually with an effective date of July 1. The premium is based on family size and income to ensure that no family pays more than 5% of their income for coverage. The formula used to calculate the monthly premium amount each year includes a factor to ensure the annual aggregate cost-sharing for a family does not exceed 5% of the family's income for the length of the child's eligibility period. At the time of application, the recipient is advised to contact their FSD Eligibility Specialist to report any changes in income, family size, or address. The monthly invoice also directs recipients to contact their Eligibility Specialist to report any changes in income, family size, or address. The recipient is asked to report any changes within 10 days of receipt of the invoice. 8.6 Describe the procedures the State will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42 CFR 457.535) Response: CMS officials have held that Missouri has no federally-recognized American Indian/Native American tribes within the state, and, therefore, Missouri has no specific obligations pursuant to 42 CFR § 457. The fact that Missouri has no federally-recognized American Indian/Native American tribes was affirmed by the CMS Region VII office as recently as May 2007.  The Eastern Shawnee Tribe of Oklahoma tribe is not associated with Missouri in the Federal Register’s “Indian Entities Recognized and Eligible To Receive Services From the United States Bureau of Indian Affairs” (Vol. 72, No. 55 / Thursday, March 22, 2007).  The Eastern Shawnee Tribe of Oklahoma (http://www.easternshawnee.org/index.html and http://www.eighttribes.org/eastern-shawnee/) listed above is actually centered on the Oklahoma/Missouri border.  Article II of the Constitution of the Eastern Shawnee Tribe (http://thorpe.ou.edu/constitution/eastshawcons.html) states that “...Eastern Shawnee lands, which are located in the north east section of the State of Oklahoma, and such other territory as may hereafter be added thereto.”

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 35B - This evidence is fully consistent with the CMS' position that Missouri has no federally- recognized American Indian/Native American tribes within the state. Recognizing that a member of a tribe may re-locate to the State, Missouri will exempt children who are members of federally-recognized tribes from cost-sharing requirements as stipulated in Section 2103(e)(1)(A). Children who identify themselves as American Indian or Native Alaskan on the SCHIP application will be notified that, upon receipt of documentation of tribal membership, they will no longer be required to submit monthly premiums. Any premiums paid will be reimbursed within 45 days of receipt of documentation of tribal membership. The materials sent to all new enrollees will include information on the cost-sharing exemption for members of federally-recognized American Indian or Native Alaskan tribes to ensure that those not indicating race on the application will be notified of this exemption. 8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42 CFR 457.570 and 457.505(c))

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 36 - Response: Premium payments are for 30 days of coverage and are paid one month in advance. A failure to pay notice is sent to recipients who have not made a payment, giving them a 30 day grace period to pay. Children with incomes between 226% and 300% of FPL have a six-month penalty applied if they fail to pay required premiums and are not eligible for coverage until the six months expire. This penalty provision does not apply to those children between 150% and 225% of FPL who may fail to pay a required premium. However, for children between 150% and 225% of FPL, coverage ends if no payment is received. Coverage for these children resumes after the next payment is received. The Notice of Case Action provides for Hearing Rights due to failure to pay a required premium.. If they request a hearing within ten days of the date of the notice, they will continue to receive benefits. Once the recipient receives an adverse action notice they can call, write, or email to request a hearing. Once the hearing request is received, the recipient is mailed a Hearing Packet which must be completed and returned. When the Hearing Packet is returned, the Hearing Unit with the Division of Legal Services (DLS) is notified. DLS sets the time and date for the hearing. The recipient can present evidence or have someone testify on their behalf. The DLS Hearing Officer asks all the questions, and the recipient and the DLS Hearing Officer are given the opportunity to respond and present evidence. After the hearing is complete the DLS Hearing Officer makes a decision based on the evidence presented. Once the decision is complete all parties are notified and whatever action is taken. 8.7.1 Please provide an assurance that the following disenrollment protections are being applied:  State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42 CFR 457.570(a))  The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non payment of cost-sharing charges. (42 CFR 457.570(b))  In the instance mentioned above, that the State will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42 CFR 457.570(b))  The State provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42 CFR 457.570(c)) Response: The Late Payment Notice notification allows

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 36A - SCHIP 1 participant Hearing Rights. If they request a hearing within ten days of the date of the notice, they will continue to receive benefits. Once the recipient receives an adverse action notice they can call, write, or email to request a hearing. Once the hearing request is received the recipient is mailed a Hearing Packet which must be completed and returned. When the Hearing Packet is returned, the Hearing Unit with the Division of Legal Services (DLS) is notified. DLS sets the time and date for the hearing. The recipient can present evidence or have someone testify on their behalf. The DLS Hearing Officer asks all the questions, and the recipient and the DLS Hearing Officer are given the opportunity to respond and present evidence. After the hearing is complete the DLS Hearing Officer makes a decision based on the evidence presented. Once the decision is complete all parties are notified and whatever action is taken. 8.8 The State assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e)) 8.8.1  No Federal funds will be used toward state matching requirements.(Section 2105(c)(4)) (42 CFR 457.220) 8.8.2  No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. Section 2105(c)(5) (42 CFR 457.224) (Previously 8.4.5) 8.8.3  No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title.(Section 2105(c)(6)(A)) (42 CFR 457.626(a)(1)) Response: It is important to note that the State is concerned that SCHIP 1 does not “crowd out” private insurance options. The following measures will help address crowd out of private insurance options: • There will be a six month look back period for health insurance when determining eligibility. Children whose parents’ available private health insurance coverage was dropped within the last six months will have a six month waiting period under SCHIP 1. Uninsured is defined as a child (children) under age 19 who does not have creditable health insurance coverage as described at 42 CFR 457.10 and 45 CFR 146.113 that minimally provides coverage for physician’s services and hospitalization. The six month look back applies. To be eligible for SCHIP 1, the child must be uninsured.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 36B - • Uninsured children are children under age 19 who do not have creditable health insurance coverage as described at 42 CFR 457.10 and 45 CFR 146.113. A child covered by health insurance at the time eligibility is determined is ineligible unless the insurance is already paid for by Missouri’s Health Insurance Premium Payment Program (HIPP). If the health insurance is dropped without good cause or the child does not have a special healthcare needs exception, the child is ineligible for six months from the month coverage ended. • The six month look back period refers to the six months prior to application. If an uninsured child lost or dropped insurance coverage in the six months prior to application, FSD explores if the reason the child is uninsured meets a good cause reason or if the child meets a special healthcare exception. • Good cause is defined as loss of insurance coverage resulting from no action taken by the insured. Good cause reasons are: • A parent's or guardian's loss of employment due to factors other than voluntary termination; • A parent's or guardian's employment with a new employer that does not provide an option for dependent coverage; • Expiration of a parent's or guardian's dependent Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage period; • Lapse of a child's (children's) health insurance when maintained by an individual other than custodial parent or guardian; • Lapse of a child's (children's) health insurance when the lifetime maximum benefits under their private health insurance have been exhausted; • Lapse of a child's (children's) health insurance when the health insurance plan does not cover an eligible child's preexisting condition; or • Discontinuance of Health Insurance Premium Payment (HIPP). • For children in families with gross income above 225% of the FPL there is a 30 day waiting period from the date of application for coverage. The 30 day waiting period does not apply to children and families with gross income below 225% FPL. These children under 225% of the FPL shall not be subject to the 30-day waiting period as long as the children meet all other qualifications for eligibility. • Any child identified as having special health care needs, defined as a condition which left untreated would result in the death or serious physical injury of a child, that does not have access to affordable employer-subsidized health care insurance will be exempt from the requirement to be without health care coverage for six months in order to be eligible for services, and the 30-day waiting period as long as the child meets all other qualifications for eligibility. Special healthcare needs are established based on a written statement from the child’s treating physician. • Children with special healthcare needs who do not have access to affordable employer-subsidized health insurance are exempt from the six month penalty

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 36C - for loss of insurance coverage without good cause and the 30 day waiting period for children in families with income of more than 225% FPL. • Children with special healthcare needs must still be uninsured to qualify and cannot have access to affordable health insurance. Access to affordable insurance available through employment, a group membership, or from a private company causes ineligibility. The affordability guidelines are: • Three percent of 150% of the FPL for a family of three, for families with a gross income of more than 150% and up to 185% FPL. • Four percent of 185% of the FPL for a family of three, for families with a gross income of more than 185% and up to 225% FPL. • Five percent of 225% of the FPL for a family of three, for families with a gross income of more than 225% but less than 300% FPL. • Children in families with gross income above 150% of the FPL cannot have access to affordable employer sponsored or private health insurance. These children must pay a premium to be eligible (a cost sharing provision). The following is a description of the affordability test: • Three percent of 150% of the FPL for a family of three, for families with a gross income of more than 150% and up to 185% FPL. • Four percent of 185% of the FPL for a family of three, for families with a gross income of more than 185% and up to 225% FPL. • Five percent of 225% of the FPL for a family of three, for families with a gross income of more than 225% but less than 300% FPL. 8.8.4  Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42 CFR 457.622(b)(5))

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 37 - 8.8.5  No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42 CFR 457.475) 8.8.6  No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42 CFR 457.475)

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 38 - Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107) 9.1 Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42 CFR 457.710(b)) Response: The State’s objectives are: 1. Reduce the number of children in Missouri without health insurance coverage. 2. Increase access to care. 3. Increase the number of children in Missouri who have access to a regular source of healthcare coverage. 4. Improve the health of Missouri’s medically uninsured children through the use of preventive care. 9.2 Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42 CFR 457.710(c)) Response: Objective 1: Reduce the number of children in Missouri without health insurance coverage. Performance goal: Increase enrollment in SCHIP 1 and SCHIP 2 of uninsured children. Baseline: The State will use the current enrollment data for SCHIP 1 and SCHIP 2 population as reported to CMS on the CMS-64EC, CMS-64.21E and entered into the Statistical Enrollment Data System as the baseline measurement. These reports show end of quarter actual and unduplicated ever enrolled figures. Please see Attachment 7. Target Improvement Level: Enroll more uninsured children. Objective 2: Increase access to care. Performance goal: Increase enrollment of physicians. Baseline: As of May 21, 2007, there were 15,605 physicians enrolled in MO HealthNet. Target Improvement Level: Enroll more physicians in MO HealthNet. Objective 3: Increase the number of children in Missouri who have access to a regular source of healthcare coverage. Performance goal: Decrease the percent of children matched to a PCP through auto- assignment. Baseline: As of May 5, 2007, 88% of recipients self-selected a PCP. Target Improvement Level: Increase the number of recipients who self-select a PCP.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 39 - Objective 4: Improve the health of Missouri’s medically uninsured children through the use of preventive care. Performance goal: Assess how many children receive recommended well visits and screens. Baseline: As of Missouri State Fiscal Year 2006, the total number of eligibles receiving at least one initial or periodic screen was 275,101. Target Improvement Level: Increase the number of recommended well visits and screens received by children. Specific measurements of the target improvement levels for the four objectives are: 1. Continue to reduce the number of uninsured children in Missouri with an overall goal of reducing the total to less than 100,000. For reference, the number of uninsured children in Missouri (calculated on the basis of CPS data) fell to a low of 46,000 in 1999, but it subsequently increased to a high of 120,000 in 2004. We will monitor our progress towards this objective by reviewing the table published annually by the U.S. Census Bureau entitled “Historical Health Insurance Tables (Table HI-5): Health Insurance Coverage by State – Children under 18.” 2. Reverse the recent declines in enrollment in the existing 1115 Waiver program and increase total SCHIP 1 and SCHIP 2 enrollment. The State aims to achieve and maintain an overall combined enrollment target of 76,000 children in SCHIP 1 and SCHIP 2 by the end of Federal Fiscal Year 2008 (see attachment 10). For reference, existing 1115 Waiver enrollment has fallen from almost 74,400 in October 2005 to roughly 63,500 in April 2007. The State will monitor progress toward this objective by reviewing the Monthly Management Report published by the Missouri Department of Social Services, Family Support Division. 3. Reverse the recent declines in the number of children subject to premium payment in the program and maintain enrollment therein at or more than 20,000 children. With the imposition of the new premium structure over the last year, enrollment in the existing 1115 Waiver has decreased from over 30,000 in October 2005 to about 20,000 in April 2007. With additional outreach and education, the State will acclimate more families to the program and restore their enrollment, and attract new families to the program as an alternative to remaining uninsured. The State will monitor progress toward this objective by reviewing the Monthly Management Report published by the Missouri Department of Social Services, Family Support Division.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 39A - 9.3 Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the State’s performance, taking into account suggested performance indicators as specified below or other indicators the State develops: (Section 2107(a)(4)(A),(B)) (42 CFR 457.710(d)) Check the applicable suggested performance measurements listed below that the State plans to use: (Section 2107(a)(4)) 9.3.1 □ The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2  The reduction in the percentage of uninsured children as measured by the number of uninsured children. 9.3.3  The increase in the percentage of children with a usual source of care. 9.3.4 □ The extent to which outcome measures show progress on one or more of the health problems identified by the State. 9.3.5 □ HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6 □ Other child appropriate measurement set. List or describe the set used. 9.3.7  If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1  Immunizations 9.3.7.2  Well child care 9.3.7.3  Adolescent well visits 9.3.7.4  Satisfaction with care 9.3.7.5  Mental health 9.3.7.6  Dental care 9.3.7.7  Other, please list:

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 40 - Response: Please see Attachment 4, MO HealthNet Managed Care Quality Improvement Strategy, Exhibits 1 and 3. 9.3.8 □ Performance measures for special targeted populations. 9.4  The State assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42 CFR 457.720) 9.5  The State assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the State’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42 CFR 457.750) Response: This population will become part of our SCHIP 1 and SCHIP 2 reporting. All necessary SCHIP 1 and SCHIP 2 reports and documentation will be submitted. Please refer to Attachment 4. 9.6  The State assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42 CFR 457.720) 9.7  The State assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42 CFR 457.710(e)) 9.8 The State assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42 CFR 457.135) 9.8.1  Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2  Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3  Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4  Section 1132 (relating to periods within which claims must be filed) 9.9 Describe the process used by the State to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42 CFR 457.120(a) and (b))

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 41 - Response: To ensure public involvement in the design and implementation of SCHIP 1 and SCHIP 2, the MO HealthNet Division considers suggestions made to the Missouri General Assembly. The Missouri General Assembly holds a series of public hearings in conjunction with the approval of the annual budget for Missouri and as they consider changes in state law. In addition, to ensure public involvement in SCHIP 1 and SCHIP 2, the Quality Assessment and Improvement Advisory (QA&I) Group, a partnership of representatives for the major stakeholders in the Missouri MO HealthNet Managed Care Program, collaborates for the purpose of:  Ensuring that high-quality care is provided to MO HealthNet managed care members enrolled in MO HealthNet managed care and helping MO HealthNet be accountable to the public and MO HealthNet managed care members;  Adopting appropriate broad measurable population-based quality indicators, including measures of access, utilization, structure, process, outcomes, member satisfaction, and risk behaviors;  Interpreting quality data prioritizing areas for improvement, and recommending improvement activities;  Monitoring the care provided to this group of MO HealthNet managed care members for serious variances from high quality processes and outcomes;  Fostering, supporting, and enhancing the quality improvement programs of individual MCOs and provider groups;  Providing a forum where quality concerns of the MO HealthNet Division, other state agencies, MCOs, providers, and MO HealthNet managed care members can be communicated, thus forming a public-private partnership dedicated to improving the health of MO HealthNet managed care members. The QA&I meetings are open to members of the public. Meeting discussions are open to group members, MO HealthNet personnel, and invited guests. The meeting agenda includes an open forum in which input from the public is solicited for discussion, comment, and review. QA&I meetings are scheduled one year in advance and held quarterly. Meeting notices are posted at the State Capitol, the Broadway Building, the DSS offices at the Howerton Building, and the Jefferson Building, and on the MO HealthNet website at http://www.dss.mo.gov/mhd/. On an ongoing basis the QA&I Advisory Group will advise the MO HealthNet Division regarding health policy that: improves the health status of MO HealthNet clients, maintains or reduces the cost of health care while maintaining or improving quality of care, and describes best practices

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 42 - The role of the QA&I subcommittees will be to evaluate, refine, and recommend sentinel indicators, recommend intervention strategies, and review satisfaction and audit data as it relates to maternal and child health and behavioral health issues. The QA&I subcommittees will also communicate provider complaints and system issues to the QA&I Advisory Committee and the MO HealthNet Division and respond to ad hoc requests of the QA&I Committee. The MO HealthNet Managed Care Consumer Advisory Committee (CAC) was formed to advise the Director of the MO HealthNet Division on issues relating to enrollee participation in the MO HealthNet Managed Care Program. The committee meets quarterly in Jefferson City and consists of a minimum of 15 enrollees and advocates. The CAC meetings provide updates from other state agencies that would impact their benefits. The MCOs also attend the meetings. CAC members are given the opportunity to suggest agenda items for each meeting. A notice of open meeting is posted prior to the meetings. The notice of open meeting includes the agenda items for the meetings. The MO HealthNet Division also conducts Quarterly All Plan Meetings for the MCOs. These meetings are an opportunity for the MO HealthNet Division and the MCOs to discuss issues related to the MO HealthNet Managed Care Program. The meetings also provide updates from other state agencies that affect the MO HealthNet Managed Care Program. A notice of open meeting is posted prior to the meetings. The notice of open meeting includes the agenda items for the meetings. The MCOs are given an opportunity to suggest agenda items for each meeting. 9.9.1 Describe the process used by the State to ensure interaction with Indian Tribes and organizations in the State on the development and implementation of the procedures required in 42 CFR part 457.125. (Section 2107(c)) (42 CFR 457.120(c)) Response: There are no federally recognized Indian Tribes and Organizations in the State. CMS officials have held that Missouri has no federally-recognized American Indian/Native American tribes within the state, and, therefore, Missouri has no specific obligations pursuant to 42 CFR § 457. The fact that Missouri has no federally- recognized American Indian/Native American tribes was affirmed by the CMS Region VII office as recently as May 2007. • The Eastern Shawnee Tribe of Oklahoma tribe is not associated with Missouri in the Federal Register’s “Indian Entities Recognized and

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 42A - Eligible To Receive Services From the United States Bureau of Indian Affairs” (Vol. 72, No. 55 / Thursday, March 22, 2007). • The Eastern Shawnee Tribe of Oklahoma (http://www.easternshawnee.org/index.html and http://www.eighttribes.org/eastern-shawnee/) listed above is actually centered on the Oklahoma/Missouri border. • Article II of the Constitution of the Eastern Shawnee Tribe (http://thorpe.ou.edu/constitution/eastshawcons.html) states that “...Eastern Shawnee lands, which are located in the north east section of the State of Oklahoma, and such other territory as may hereafter be added thereto.” This evidence is fully consistent with the CMS' position that Missouri has no federally- recognized American Indian/Native American tribes within the state. Recognizing that a member of a tribe may re-locate to the State, Missouri will exempt children who are members of federally-recognized tribes from cost-sharing requirements as stipulated in Section 2103(e)(1)(A). Children who identify themselves as American Indian or Native Alaskan on the SCHIP application will be notified that, upon receipt of documentation of tribal membership, they will no longer be required to submit monthly premiums. Any premiums paid will be reimbursed within 45 days of receipt of documentation of tribal membership. The materials sent to all new enrollees will include information on the cost-sharing exemption for members of federally-recognized American Indian or Native Alaskan tribes to ensure that those not indicating race on the application will be notified of this exemption. 9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in part 457.65(b) through (d). Response: The Missouri General Assembly holds a series of public hearings in conjunction with the approval of the annual budget for Missouri and as they consider changes in State law. Once the hearings are complete and the budget has been approved, the premium amounts are calculated. A notice is mailed to affected individuals 30 days prior to implementation of changes. A monthly invoice is mailed to participants thirty days in advance, billing them for the next month's premium. The premium chart and information regarding premiums is posted on the Department of Social Services' website and in outreach and educational materials. Public Notice is also provided through amendments to 13 CSR 70-4.080, State Children's Health Insurance Program, published in the Missouri Register with a 30 day public comment period.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 42A -

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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 43 - 9.10 Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42 CFR 457.140) • Planned use of funds, including - o Projected amount to be spent on health services; o Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and o Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. Response: Benefit Costs Insurance Payments Total projected costs for the SCHIP 1 and SCHIP 2 populations. Federal Fiscal Year (FFY) 2009 expenditures include actual expenditures of the one quarter available and projected expenditures of the three quarters not yet available. Based on the last year of historical expenditures, the State expects a 2% annual trend. Member months are calculated from the CMS 64.21E Line 1, per CMS instructions. FFY 2009 member months include actual member months of the one quarter available and projected member months of the three quarters not yet available. Based on the last year of historical expenditures, the State expects member months to grow approximately .50% annually.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 43A -

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Missouri Application for the State Children’s Health Insurance Program Effective Date: 07/01/2011 Approval Date: Bold/Italics Added Information Prior Approval Date: 05/01/2009 Strikethrough Deleted Information - 44 - PMPM is calculated by the average monthly Total Costs divided by Member Months. Beneficiary Cost Sharing Payments The premium amount expected to be collected during FFY 2009 and FFY 2010. Based on the last year of historical cost sharing payments, the State expects a 2% annual trend. Children ages birth through 18 with family income between 150% and 300% FPL are required to pay a monthly premium. Net Benefit Cost Insurance Payments less Beneficiary Cost Sharing Payments. Administration Costs FFY 2009 expenditures include actual expenditures of the one quarter available and projected expenditures of the three quarters not yet available. Based on the last year of historical expenditures, the State is projecting an increase in administrative costs. The State expects administrative costs to grow approximately 2.0% annually.

Health Services Initiatives

Since we are requesting an effective date of July 1, 2011, the FFY 2012 expenditures include actual expenditures of the two (2) quarters available, projected expenditures of the two quarters not yet available, and the projected expenditures of the Health Services Initiative.

The source of expenditures for the Health Services Initiative is Local Public Health Agencies (LPHAs) who use Certifications of Public Expenditures (CPE) to demonstrate that the funds are local and state in origin.

Based on the last year of historical expenditures and the inclusion of the “Health Services Initiatives” the State is projecting an increase in administrative costs. The increase falls within the 10% Administrative Cost Ceiling. Please see Attachment 8.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 45 - Section 10. Annual Reports and Evaluations (Section 2108) 10.1 Annual Reports. The State assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42 CFR 457.750) 10.1.1  The progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and 10.2  The State assures it will comply with future reporting requirements as they are developed. (42 CFR 457.710(e)) 10.3  The State assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 46 - Section 11. Program Integrity (Section 2101(a)) □ Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12. 11.1  The State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42 CFR 457.940(b)) 11.2 The State assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42 CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1  42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2  Section 1124 (relating to disclosure of ownership and related information) 11.2.3  Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4  Section 1128A (relating to civil monetary penalties) 11.2.5  Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6  Section 1128E (relating to the National health care fraud and abuse data collection program) 11.3 Fraud and Abuse Response: The delivery systems described below apply to MO HealthNet, SCHIP 1 and SCHIP 2. MO HealthNet Fee-For-Service Delivery System Fraud and Abuse Detection System (FADS) -- Thomson Medstat’s Advantage Suite® for Fraud Detection is a comprehensive, multi-functional solution for identification and investigation of fraud, waste, and abuse. It provides financial, utilization, eligibility, and quality of care reporting capabilities; in addition, it provides rules-based capabilities for detecting and investigating potential fraud, abuse and waste. The system detects known patterns of aberrant behavior and can automatically “alert” the user when such a pattern is detected. It provides drill-down paths and ad hoc inquiry capabilities to support data investigation at the

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 47 - provider, recipient, and detailed claim level. The Advantage Suite database provides users with access to integrated MO HealthNet Division paid and denied healthcare claims, managed care encounter records, provider enrollment information, eligibility data, financial records, and other detail-level data. If the review findings question the provider’s license or certification, an appropriate referral is made to the Missouri Division of Professional Registration. If the review findings question the practitioner’s Bureau of Narcotic and Dangerous Drugs (BNDD) prescribing privileges, the appropriate referral is made to BNDD. If a question of potential fraud exists, the case is referred to the Office of Attorney General/MO HealthNet Fraud Control Unit (OAG/MFCU). Missouri Statute allows for the MO HealthNet provider’s appeal of the result of the MO HealthNet Division's post payment reviews. If the provider is adversely affected by the MO HealthNet Division's decision, he/she may appeal the decision to the Administrative Hearing Commission. Missouri Medicaid Audit and Compliance (MMAC) Unit is the agency within the Missouri DSS that is responsible for referring all cases of suspected provider fraud to the OAG/MFCU. The Missouri DSS has a Memorandum of Understanding (MOU) with OAG/MFCU. One of the requirements of the MOU is to conduct monthly meetings to exchange information and discuss potential cases. Evaluation criteria are based on the specific requirements stated in each program’s MO HealthNet Manual and updated by MO HealthNet Bulletins. All programs are evaluated for adequate documentation. The MMAC Unit conducts post payment reviews of MO HealthNet providers to determine the propriety of claims reimbursed by MO HealthNet and monitors the utilization of MO HealthNet services in the State. Following a preliminary review, if the reviewer is suspicious of fraud the case must be referred to the OAG/MFCU. Suspicion of fraud can be determined by unexplained or unreasonable billing patterns. In a preliminary review by Program Integrity staff the reviewer is comparing the claim data to the provider’s treatment records. Suspicion of fraud can be repeated findings of lack of documentation (false claims), up coding (billing higher level codes than what is documented), and/or inadequate documentation. MO HealthNet providers are selected to be reviewed from either referral, exception reports, and/or other system generated reports. Referrals concerning possible misutilization may be received from providers, recipients, consultants,

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 48 - employees of the MO HealthNet Division, as well as staff from other agencies. Exception reports are produced on providers that have exceptional patterns of utilization, or that deviate from established norms. Medstat/Advantage Suite leads are on providers and recipients who have a suspected pattern of waste or abuse. A review of MO HealthNet claims reimbursed is performed on each of the selected providers or project in order to determine program compliance. This review is completed by either desk review or field review. The appropriateness and quality of service are also considered for the claims being reviewed. If a question regarding the quality of service, medical necessity or medical interpretation exists, the case is referred to the Division’s State Consultant(s) for review. The final outcome of a provider review may include one or more of the following administrative actions: determination of overpayment, withholding of payments, transfer to closed-end agreement, provider education, prepayment review, referral to another state agency, or suspension or termination of the provider’s MO HealthNet participation agreement. If an overpayment is identified, a certified mailing is sent to the provider outlining all errors noted in the review and informing the provider of the total amount overpaid. The provider is also notified of any repayment options available to them. The MMAC Unit monitors MO HealthNet recipient utilization of services. The MMAC Unit uses several resources including, but not limited to, the Fraud and Abuse Detection System and referrals, to detect MO HealthNet recipient aberrant utilization patterns. Recipients with a pattern of suspected abuse are reviewed by Program Integrity staff to determine if there is legitimate cause for the excessive utilization or if there is suspicion of possible abuse of the MO HealthNet Program. Based on the outcome of the analysis, the recipient is educated regarding the appropriate use of MO HealthNet services or, if warranted, the recipient is placed on Lock–In status if the utilization pattern is not supported by a medical need. The recipient can be locked-in to a pharmacy or to a physician or to both based on the aberrant behavior. Suspicion of recipient fraud, such as MO HealthNet identification card sharing and false income reporting, is referred to the MO HealthNet Investigation Unit within the DSS for further investigation and referral to law enforcement. MO HealthNet Managed Care Delivery System In accordance with Missouri Statute, MO HealthNet Managed Care contract requirements, and policy statements regarding fraud and abuse, the MCOs must perform fraud and abuse prevention, coordination, detection, investigation, and enforcement

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 49 - regarding fraud and abuse activities by, but not limited to, MCOs, providers, subcontractors, MO HealthNet beneficiaries, MO HealthNet managed care enrollee or employees. The MCOs must report to and cooperate with the DSS, MO HealthNet Division and other key players as appropriate. On a quarterly basis, the MCOs report fraud and abuse activities, to the Quality Services Unit of the MO HealthNet Division, as indicated in the QI Strategy. Each MCO must implement internal controls, policies and procedure for prevention, coordination, detection, investigation, enforcement and reporting of fraud and abuse in accordance with the MO HealthNet Managed Care contract and the MCO's Fraud and Abuse Plan. The policies and procedures shall articulate the MCO's commitment to comply with all applicable federal and state standards. The MCO's Fraud and Abuse Plan must designate a compliance officer and compliance committee that is responsible for the Fraud and Abuse Program and activities. The MCO must submit a written Fraud and Abuse Plan to the state agency for approval prior to implementation. Any changes to the approved fraud and abuse plan must have state agency approval prior to implementation. 11.3.1 In accordance with the Recipient Lock-In Program, the MCOs must implement a method to limit or restrict the use of the recipient's MO HealthNet identification care to designated providers of medical services. The MCO must submit its lock- in policies and procedures to the state agency for approval prior to implementation. When a member or provider is suspected of fraud or abuse, the MCO notifies the state agency of the suspected activity as well as includes the information in their quarterly reporting.

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 50 - Section 12. Applicant and enrollee protections (Sections 2101(a)) □ Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan. Eligibility and Enrollment Matters 12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR part 457.1120. Response: Missouri maintains an independent State fair hearing process as required by federal law and regulation, as amended for MO HealthNet, SCHIP 1, and SCHIP 2. The State fair hearing process shall provide recipients an opportunity for a State fair hearing before an impartial hearing officer. The parties to the State fair hearing include recipients, his or her representative, or the representative of a deceased recipient's estate, and the MCOs if applicable. The State agency and/or MCO shall comply with decisions reached as a result of the State fair hearing process. MO HealthNet, SCHIP 1, and SCHIP 2 recipients have the right to request information regarding: • The right to request a State fair hearing. • The procedures for exercising the rights to appeal or request a State fair hearing. • Representing themselves or use legal counsel, a relative, a friend, or other spokesperson. • The specific regulations that support or the change in federal or state law that requires the action. • The individual’s right to request a State fair hearing, or in cases of an action based on change in law, the circumstances under which a hearing will be granted. • A State fair hearing within 90 calendar days from the MCOs notice of action. The State must reach its decisions within the specified timeframes: • Standard resolution: • Within 90 calendar days of the date the member filed the appeal with the MCO if the member filed initially with the MCO (excluding the days the enrollee took to subsequently file for a State fair hearing) or the date the member filed for direct access to a State fair hearing. • Expedited resolution (if the appeal was heard first through the MCO appeal process): within three working days from the state agency’s receipt of a hearing request for a denial of a service that:

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 51 - • Meets the criteria for an expedited appeal process but was not resolved using the MCOs expedited appeal timeframes, or • Was resolved wholly or partially adversely to the member using the MCOs expedited appeal timeframes. Expedited resolution (if the appeal was made directly to the State fair hearing process without accessing the MCO appeal process): within three working days from the state agency’s receipt of a hearing request for a denial of a service that meets the criteria for an expedited appeal process. Health Services Matters 12.1 Please describe the review process for health services matters that complies with 42 CFR part 457.1120. Response: Missouri maintains an independent State fair hearing process as required by federal law and regulation, as amended for MO HealthNet, SCHIP 1, and SCHIP 2. The State fair hearing process shall provide recipients an opportunity for a State fair hearing before an impartial hearing officer. The parties to the State fair hearing include recipients, his or her representative, or the representative of a deceased recipient's estate, and the MCOs if applicable. The State agency and/or MCO shall comply with decisions reached as a result of the State fair hearing process. MO HealthNet, SCHIP 1, and SCHIP 2 recipients have the right to request information regarding: • The right to request a State fair hearing. • The procedures for exercising the rights to appeal or request a State fair hearing. • Representing themselves or use legal counsel, a relative, a friend, or other spokesperson. • The specific regulations that support or the change in federal or state law that requires the action. • The individual’s right to request a State fair hearing, or in cases of an action based on change in law, the circumstances under which a hearing will be granted. • A State fair hearing within 90 calendar days from the MCO's notice of action. The State must reach its decisions within the specified timeframes: • Standard resolution: • Within 90 calendar days of the date the member filed the appeal with the MCO if the member filed initially with the MCO (excluding the days the

Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 52 - enrollee took to subsequently file for a State fair hearing) or the date the member filed for direct access to a State fair hearing. • Expedited resolution (if the appeal was heard first through the MCO appeal process): within three working days from the state agency’s receipt of a hearing request for a denial of a service that: • Meets the criteria for an expedited appeal process but was not resolved using the MCOs expedited appeal timeframes, or • Was resolved wholly or partially adversely to the member using the MCOs expedited appeal timeframes. Expedited resolution (if the appeal was made directly to the State fair hearing process without accessing the MCO appeal process): within three working days from the state agency’s receipt of a hearing request for a denial of a service that meets the criteria for an expedited appeal process. Premium Assistance Programs 12.2 If providing coverage through a group health plan that does not meet the requirements of 42 CFR part 457.1120, please describe how the State will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

Missouri Application for the State Children’s Health Insurance Program Attachment 8 – Page - 1 -

Attachment 8 CHIP Budget

STATE: Missouri FFY Budget FFY Budget Federal Fiscal Year 2011 Costs 2012 Costs State’s enhanced FMAP rate 74.30% 74.42%

Benefit Costs

Insurance payments

Managed care $ 76,455,793 $ 81,165,815 FFY 2011: ($142.17 PMPM @ 44,814 eligibles)

FFY 2012: ($149.95 PMPM @ 46,410 eligibles)

Fee for Service $ 81,100,876 $ 84,478,706 FFY 2011: ($189.90 PMPM @ 35,589 eligibles)

FFY 2012: ($203.87 PMPM @ 36,859 eligibles)

Total Benefit Costs $ 157,556,669 $ 165,644,521 (Offsetting beneficiary cost sharing payments) $ (4,905,170) $ (4,905,170) Net Benefit Costs $ 152,651,499 $ 160,739,351 Cost of Proposed SPA Changes – Benefit

Administration Costs

Personnel

General administration

Contractors/Brokers $ 2,917,877 $ 3,186,801 Claims Processing

Outreach/marketing costs

Health Services Initiatives $ 1,150,000 $ 4,600,000 Other

Total Administration Costs $ 4,067,877 $ 7,786,801 10% Administrative Cap $ 16,961,278 $ 17,859,928

Cost of Proposed SPA Changes $ 1,150,000 $ 4,600,000

Federal Share $ 116,442,496 $ 125,417,162 State Share $ 40,276,880 $ 43,108,990 Total Costs of Approved CHIP Plan $ 156,719,376 $ 168,526,152

NOTE: The Federal Fiscal Year (FFY) runs from October 1st through September 30th. FFY actuals through Quarter ending March 31, 2012. Remaining Quarters are projected.

The Source of State Share Funds:

Missouri Application for the State Children’s Health Insurance Program Attachment 8 – Page - 2 -

Source of State Funds are 16% of General Revenue under the Current House Bill. The remaining is a combination of general revenue equivalents. The general revenue equivalents source of State funds are Medicaid Managed Care Organization Allowance Fund, Federal Reimbursement Allowance Fund, Health Initiatives Fund, Pharmacy Rebates Fund, Premium Fund, and Federal Funds. These non-federal funding sources are appropriated by the Missouri General Assembly. Missouri’s hospital tax is titled the Federal Reimbursement Allowance Fund which is a general revenue equivalent. The reference to the Federal Fund is the federal dollars earned from claims which is appropriated by the General Assembly. The non-federal funding sources are the sources previously listed as Medicaid Managed Care Organization Allowance Fund, Federal Reimbursement Allowance Fund, Health Initiatives Fund, Pharmacy Rebates Fund, and Premium Fund.

Revised 7/12

1

MISSOURI TITLE XXI PROGRAM & AMENDMENT FACT SHEET

Name of Plan: SCHIP 1 (Separate CHIP)

SCHIP 2 (Medicaid Expansion Program)

Date Plan Submitted:

September 26, 1997 Date Plan Approved:

April 28, 1998 Effective Date of Plan:

October 1, 1997 Implementation Date:

September 1998

Date Amendment #1 Submitted: August 8, 2002 Date Amendment #1 Approved:

November 6, 2002

Date Amendment #2 Submitted: July 1, 2004 Date Amendment #2 Approved:

September 30, 2004 Date Amendment #2 Effective:

July 1, 2004

Date Amendment #3 Submitted:

May 31, 2007 Date Amendment #3 Approved:

September 28, 2007 Date Amendment #3 Effective:

September 1, 2007

Date Amendment #4 Submitted:

May 8, 2008 Date Amendment #4 Disapproved: December 19, 2008 (Disapproved)

Date Amendment #5 Submitted:

February 20, 2009 Date Amendment #5 Approved:

August 7, 2009 Date Amendment #5 Effective:

May 1, 2009

Date Amendment #6 Submitted:

August 19, 2009 Date Amendment #6 Approved:

September 24, 2009 Date Amendment #6 Effective:

July 1, 2009

Date Amendment #7 Submitted:

June 3, 2011 Date Amendment #7 Withdrawn: June 29, 2011 (Withdrawn)

Background • Effective October 1, 1997, Missouri’s initial Title XXI State Plan expanded Medicaid eligibility to children in families with gross income up to 300 percent of the Federal Poverty Level (FPL).

2

• Effective September 1, 2007, the State created a Combination program by adding a new Separate Child Program (called SCHIP 1). Following is a chart depicting the CHIP eligibility coverage:

Amendments • On August 8, 2002, Missouri submitted its first CHIP State plan amendment (SPA). The amendment updated and amended the Title XXI State plan to indicate compliance with the final CHIP regulations.

• On July 1, 2004, Missouri submitted its second amendment to exempt children with special health care needs from the State’s 6-month period of uninsurance and from the 30-day waiting period.

• On May 31, 2007, Missouri submitted its third amendment which created a Title XXI Combination program, with a Separate CHIP component, MC+ for Kids program. Under the Separate program, uninsured children from birth to age 1, in families with income of more than 185 percent and up to and including 300 percent of the FPL are covered; and, age 1 through 18 with income of more than 150 percent of the FPL and up to and including 300 percent of the FPL are also covered. Under the Medicaid expansion, children from age 1 through 5, in families above 133 percent and up to and including 150 percent of the FPL are covered; and, those age 6 through 18 in families above 100 percent and up to and including 150 percent are also covered under the Medicaid Expansion program.

• On May 8, 2008, Missouri’s fourth CHIP SPA modified the eligibility requirements for targeted low income children to allow them to be eligible when they exceed their annual coverage limit and pre-existing conditions limit. It also changed the premium schedule effective July 1, 2008, through March 31, 2009, and replaced the dollar amounts of the affordability levels with the percentages applied to the effected FPLs. In addition the SPA changed the name of the State’s Separate Child Health Program to CHIP 1 and the Medicaid Expansion Program to CHIP 2. (Note: CMS disapproved this amendment on December 19, 2008.)

• On February 20, 2009, Missouri’s fifth CHIP amendment made several technical changes and clarifications to its CHIP State Plan as described below:

- Clarified the State’s current premium formula and modified its premium structure so that premiums are based on annual changes in the FPLs rather than providing specific amounts within the State Plan. This has not changed the amount of cost sharing that enrollees are currently charged.

Age FPL

Medicaid Expansion Separate CHIP Birth to 1 year

Above 185% - 300% 1 year thru 5 years Above 133% - 150% Above 150% - 300% 6 thru 18 years Above 100% - 150% Above 150% - 300%

3

- Provided greater detail and clarified the State’s premium assistance program and correctly indicated that Missouri has a Purchase of Family Premium Assistance Program. Prior to this SPA it was unclear that the State provided premium assistance to its Separate Child Health Program enrollees.

- Changed Missouri’s CHIP State Plan Program name to SCHIP 1 for its Separate Child Health Program and SCHIP 2 for its Medicaid Expansion Program.

• On August 19, 2009, Missouri’s sixth CHIP amendment exempted temporary income earned while working for the decennial census from the eligibility calculations for CHIP new applicants and enrollees at redetermination.

• On June 3, 2011, Missouri’s seventh CHIP amendment proposed to provide CHIP coverage to children of public employees. (Note: The State withdrew this amendment on June 29, 2011.)

Children Covered Under the Program In Federal Fiscal Year 2010, Missouri reported 141,236 children were ever enrolled in CHIP, of that total 86,201 were in its Separate CHIP and 55,035 were in the Medicaid Expansion Program.

Administration The program is administered by the State Medicaid Agency within the Missouri Department of Social Services.

Health Care Delivery System and Benefit Package Children eligible under the Medicaid Expansion program receive the Title XIX health care benefit package. Children eligible under the Separate CHIP program receive the Medicaid benefit package with the exception of non-emergency transportation. Coverage for CHIP enrollees is provided through the managed care delivery system in the 54 counties in which Missouri’s Section 1915(b) waiver operates. In the remaining counties, CHIP coverage is provided through a fee for service system.

Cost Sharing • No cost sharing is charged for the Medicaid Expansion enrollees, but the Separate CHIP enrollees are charged premiums based on family income. (The State’s computer system does not allow an enrollee to pay more than 5 percent of its family's gross income on premiums.)

• Missouri uses a premium formula structure outlined by its State Legislature as follows:

- Children with family incomes between 150 percent and 185 percent of the FPL are charged a premium of 4 percent of their family income.

4

- Children with family incomes between 185 percent and 225 percent of the FPL are charged 4 percent of their family income up to 185 percent plus 8 percent of their family income above 185 percent.

- Children with family incomes between 225 percent and 300 percent of the FPL are charged 4 percent of their family income up to 185 percent, plus 8 percent of their family income above 185 up to 225 percent, plus 14 percent of their income between 225 percent and 300 percent of the FPL.

Crowd-Out Strategy • Crowd out will be evaluated yearly to determine if additional protections are warranted.

• Children, who have had private coverage within the last 6 months, have a 6-month lock-out period for Medicaid Expansion coverage.

• The Separate CHIP conducts a 6-month look-back period of health care uninsurance.

 In addition to the 6-month look-back period from the time of application, a 30-day lock- out period is required for children in families with incomes above 225 percent of the FPL.

 Children and families with gross income below 225 percent of the FPL are exempt from the 30-day lock-out for coverage.

 Children with special needs are also exempt from the 6-month look-back period and the 30-day lock-out period as long as these children meet all other qualifications for eligibility.

 To be eligible for the Separate CHIP, the child must be uninsured. An uninsured child is defined as a child under age 19 who does not have health insurance that minimally provides coverage for physician’s services and hospitalization. Children covered by health insurance at the time eligibility is determined are ineligible unless the insurance is already paid for by Missouri’s Health Insurance Premium Payment Program (HIPP). If the health insurance is dropped, without good cause or the child does not have a special health care needs exception, the child is ineligible for 6 months from the date of the month coverage ended.

• Access to affordable insurance health insurance available through employment, a group membership or from a private company causes ineligibility. The affordability guidelines are:

Percentage of FPL Family of 3 with Gross Income 3 percent of 150% >150% and up to185% of the FPL 4 percent of 185% >185% and up to 225% of the FPL 5 percent of 225% >225% but less than 300% of the FPL

5

Outreach Activities • The State uses brochures and informational flyers to educate families about the health coverage available through Medicaid. The MC+ Consumer Advisory Committee, the Family Support Division staff, the Department of Health and Senior Services, school districts and other appropriate agencies or groups assist in the design and implementation of the brochures and flyers. The State continues to coordinate eligibility outreach efforts with schools, hospitals, and local public health agencies by identifying barriers to Medicaid.

• The outreach strategies for Missouri’s MC+ for Kids Program will utilize and build upon the current outreach strategies for the MO HealthNet program. In addition, the State also shares information about the MC+ for Kids Program through, the press, public speaking opportunities of the executive agency staff, public service announcements and managed care organizations.

Total FFY 2011 CHIP Allotment: $243,841,719 Financial Information FFY 2011 Enhanced Federal Matching Rate: 74.30%

Date Last Updated: CMS, CMCS, CAHPG, DCHIP, October 14, 2011

DEPARTMENT OF HEALTH & HUMAN SERVICES a Centers for Medicare & Medicaid Services as

7500 Security Boulevard, Mail Stop $2-01-16 f RA he, Baltimore, Maryland 21244-1850 .

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

NOV 1 3 2015

Joseph Parks, MD

Director, MO HealthNet Division Department of Social Services 615 Howerton Court

Jefferson City, MO 65109

Dear Dr. Parks:

Tam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MO-14-0017, submitted on May 30, 2014, with additional information provided on November 9, 2015. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number MO-14-0017 converts the state’s pre-Affordable Care Act income eligibility standards to MAGI-equivalent standards, by age group, for children covered in its title XXI- funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop $2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator (ARA) in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12" Street, Room 355

Kansas City, MO 64103-2808

Page 2 — Dr. Joseph Parks

Congratulations on the approval. If you have additional questions, please contact Mr. Manning Pellanda, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely, dD (a Marie Costello Acting Director

Enclosure

cc: James G. Scott, ARA, CMS Region VII

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) 6 148 150 19 110 150

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

NOV 1 3 2015

SPA# MO-14-0017 Approval Date: Effective Date: January 1, 2014 Page | of |

_____________________________________________________________________________

Table of Contents

State/Territory Name: Missouri

State Plan Amendment (SPA) #: MO-14-0018

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Missouri consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES a

Centers for Medicare & Medicaid Services io

7500 Security Boulevard, Mail Stop $2-01-16 f q RA & Baltimore, Maryland 21244-1850 \

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES.

Children and Adults Health Programs Group

NOV 1 3 2015

Joseph Parks, MD

Director, MO HealthNet Division Department of Social Services 615 Howerton Court

Jefferson City, MO 65109

Dear Dr. Parks:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MO-14- 0018, submitted on March 31, 2014, with additional information provided on November 9, 2015. This SPA is related to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

In SPA number MO-14-0018, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and:to Mr. James G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott’s address is:

Page 2-Dr. Joseph Parks Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Richard Bolling Federal Building 601 East lih St, Room 355 Kansas City, MO 64103-2808 Congratulations on the approval. If you have additional questions, please contact Mr. Manning Pellanda, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. Sincerely, Larie CostM Acting Director Enclosures cc: James G. Scott, Associate Regional Administrator, CMS Region VII ..

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MO.0921.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Missouri State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MO-14-0018 Type of SPA:  I Medicaid Expans ish 2101(f) Gr Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320; 2102(b)(1)(B)(v) of the SSA Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page

Submitted By: Emily Rowe Last Revision Date: Aug 7, 2014 Submit Date: Mar 31, 2014 Character Count:187 out of 2000   This SPA establishes MAGI eligibility methodologies for Targeted Low Income Children. In addition it establishes MAGI-nased methodologies for Separate Children's Health Insurance Program. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov

coms. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child Health Insurance Program —_ CS15 MAGI-Based Income Methodologies eas : : —

2102(b)(1)(B\(v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups. as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013. MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility. whichever is later.

If the state covers pregnant women. in determining family size for the eligibility determination of a pregnant woman. she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: @ The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself. plus one. Cc The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants. financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: .C Current monthly household income and family size. @ Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (J Include a prorated portion of the reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support. exceeding nominal amounts. provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent.

es

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

NOV 1 3 2015 SPA# MO-14-0018 Approval Date: Effective Date: January ‘eo age | of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05. Baltimore. Maryland 21244-1850.

V.20130917

NOV 1 3 2015

SPA# MO-14-0018 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

coms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS7

Separate Child Health Insurance Program Eligibility - Targeted Low-Income Children _

2102(b)(1 (B)(v) of the SSA and 42 CFR 457.310, 315 and 320

iw Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state. .

The CHIP Agency operates this covered group in accordance with the following provisions: Age Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income

. No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL)

+ Ilo 1 196 300

+ Th 19 150 300

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

Special Program for Children with Disabilities Does the state have a special program for children with disabilities? | Yes Is the program available to all eligible targeted low-income children?

Program Description

SPA# MO-14-0018 Approval Date: NOV { 3 2015 Effective Date: January 1.20" age 1 of 2

cms. CHIP Eligibility

Describe disability criteria used.

Children who are at increased risk for a disease, defect or medical condition that may hinder their normal physical growth and development who are at or below 300% of FPL.

Describe program. including additional benefits offered.

Service coordination is provided to all participants. regardless of financial status for: i Outreach/Identification and Referral/A pplication Eligibility Determination

Assessment of Needs

Resource identification, referral and access Family support

Service Plan Development/Implementation Monitoring and Evaluation

Transition/Closure

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response. including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS. 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130917

NOV 1 3 2015

SPA# MO-14-0018 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Missouri

State Plan Amendment (SPA) #: MO-14-0019

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Missouri consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (CMs 7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & chur ence

Children and Adults Health Programs Group

JUN 25 2014

Joseph Parks, MD

Director, MO HealthNet Division Department of Social Services 615 Howerton Court

Jefferson City, MO 65109

Dear Dr. Parks:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MO-14-0019 submitted on March 31, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number MO-14-0019 describes the state’s plan to provide coverage in its separate CHIP, for children subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved CS14 is attached, and should be incorporated within a separate subsection under section 4.1 of Missouri’s approved CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment and other CHIP-related issues. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator (ARA) in our Kansas City Regional Office. Mr. Scott’s address is:

Page 2 — Dr. Joseph Parks

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12" Street, Room 355

Kansas City, MO 64103-2808

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs at (410) 786-5920.

Sincerel

- Eliot Fishman Director

Enclosure

ce: James G. Scott, ARA, CMS Region VII, Kansas City

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MO.0923.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Missouri State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MO-14-0019 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion  ish 2101(f) Gr Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page

Submitted By: Debbie Meller Last Revision Date: May 30, 2014 Submit Date: Mar 31, 2014 Character Count:198 out of 2000   Child Health Insurance Program establishes procedures for children determined ineligible for Medicaid as a Result of the elimination of income disregards due to implementation of MAGI methodologies. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov

ccms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

csi4

Section 2101(f) of the ACA and 42 CFR 457.3 10(d)

{i Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.3 10(d). Coverage for this population will cease when the last child protected

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage ina separate CHIP (expected to be no later than April 1, 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 2101(1) protection will qualify for the state’s existing separate CHIP.

A The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods. The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

(% FPL,

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

@ This population will be provided the same benefits as are provided to children in the state’s Medicaid program.

C This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

SPA# MO-14-0019 Approval Date: JUN 2 5 2014 Effective Date: January 1, 2014 Page | of 2

CEMS —_._ CHIP Eligibility

( Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. @ No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

C Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148, The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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SPA# MO-14-0019 Approval Date: Effective Date: January 1, 2014

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_____________________________________________________________________________

Table of Contents

State/Territory Name: Missouri

State Plan Amendment (SPA) #: MO-14-0020

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Missouri consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop $2-01-16

Baltimore, Maryland 21244-1850

N

CENTERS FOR MEDICARE & MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

NOV 1 8 2015

Joseph Parks, MD

Director, MO HealthNet Division Department of Social Services 615 Howerton Court

Jefferson City, MO 65109

Dear Dr. Parks:

Tam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MO-14- 0020, submitted on March 31, 2014, with additional information provided on November 9, 2015. This SPA is related to Modified Adjusted Gross Income (MAGI) Eligibility and has effective dates of January 1, 2014 and September 1, 2014.

Missouri’s SPA number MO-14-0020 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, and non- payment of premiums. We are enclosing copies of the approved state plan pages, and these approved pages supersede sections of Missouri’s current state plan and have effective dates as

detailed below:

New State Plan Page

Impact on Current State Plan Section

Effective Date

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

January 1, 2014

CS18: Non-Financial Eligibility-— | Section 4.1.0; 4.1-LR; 4.1.1-LR | January 1, 2014 Citizenship CS19: Non-Financial Eligibility— | Section 4.1.9.1 January 1, 2014

Social Security Number

CS20: Non-Financial Eligibility— | Section 4.4.4 September 1, 2014 Substitution of Coverage CS21: Non-Payment of Premiums | Section 8.7 September 1, 2014

Your title XX] project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Page 2 — Dr. Joseph Parks

Facsimile: (410) 786-5882 E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12" St, Room 355

Kansas City, MO 64103-2808

Congratulations on the approval. If you have additional questions, please contact Mr. Manning Pellanda, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff.

Anne Marie Costello Acting Director

Enclosures

ce: James G. Scott, Associate Regional Administrator, CMS Region VII

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MO.0924.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Missouri State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MO-14-0020 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing  Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320;Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page

Submitted By: Debbie Meller Last Revision Date: Nov 13, 2015 Submit Date: Mar 31, 2014 Character Count:199 out of 2000   Non financial eligibility requirements including residency, citizenship/immigration; social security number; substitution of coverage; premium lock outs, access to affordable coverage; and uninsured. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov

ner rom GEREN a aaTCANE EINE

ccms CHIP Eligibility

State Name: [Missouri |

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

42 CFR 457.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

im A non-institutionalized child. if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [M] A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides. .

ia An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

fl] A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of fl residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [I] A non-institutionalized pregnant woman who is living in the state and:

1, Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

2. Entered with a job commitment or seeking employment, whether or not currently employed.

iw An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, includitig foster care homes. by an agency of the state, or

iw An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

cl A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

mi NOV-+ 82015 SPA #: MO-14-0020 Approval Date:

Effective Date: January 1, 2014 Page I of 2

coms. CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. ()

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20140415

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SPA #: MO-14-0020 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

C818

va

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship ‘ The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens.

including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[im] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date Yes earlier than the date the notice is received by the individual.

The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

C Other date, as described:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing No in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state N also elects to cover lawfully residing children. A state may not select this option untess the state also covers Targeted Low- °

Income Pregnant Women. NOV 18 2015

SPA #: MO-14-0020 Approval Date:

Effective Date: January 1, 2014 Page | of 2

coms CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130917

NOV 1 8 2015

SPA #: MO-14-0020 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

ccmMs CHIP Eligibility

OMB Control Number: 0938-1148 xpiration date: 10/31/2014

Separate Non-Financ

42 CFR 457.340(b)

Social Security Number

Asa condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as

determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

rl The CHIP Agency assists individuals. who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[m] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205

and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their es SSN.

When requesting an SSN for non-applicant household members, the state assures that:

ry At the time such SSN is requested. the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

a The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

NOV 1 8 2015

SPA #: MO-14-0020 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

coms CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05. Baltimore, Maryland 21244-1850.

V.20130917

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SPA #: MO-14-0020 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

State Name:|Missouri

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2102(b)(3)(C) of the SSA and 42 CFR 457.340(d)(3), 457.350(i), and 457.805

Substitution of Coverage

[m] Substitution of coverage prevention strategy:

iw The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

Name of policy

Description

The joint Medicaid/CHIP application, | asks the applicant to report any health _ | insurance coverage. If the family , | reports creditable coverage (coverage ‘| that includes both doctor and hospital

"| coverage), the child will be found

ineligible. There is no waiting period for children.

The Agency tracks the number of individuals denied eligibility for CHIP due to creditable coverage as well as individuals who dropped insurance coverage without good cause. If substitution exceeds ten

(10) percent, the Agency will collaborate with CMS to identify a strategy to reduce substitution.

To be eligible, a child must not have access to affordable insurance coverage. "Affordable employer- sponsored health care insurance or other affordable health care coverage" -| refers to health insurance requiring a |monthly premium of:

"| (1) Three percent of one hundred fifty

percent of the federal poverty level for a family of three for families with a gross income of more than one hundred fifty and up to one hundred eighty-five percent of the federal

_| poverty level for a family of three;

SPA #: MO-14-0020

Approval Date:

NOV 1 8 2015

Effective Date: September 1, 2014

Page | of 2

CMs CHIP Eligibility

(2) Four percent of one hundred eighty-five percent of the federal poverty level for a family of three for a family with a gross income of more than one hundred eighty-five and up to two hundred twenty-five percent of the federal poverty level;

F | (3) Five percent of two hundred xX | twenty-five percent of the federal ' poverty level for a family of three for a family with a gross income of more than two hundred twenty-five but less than three hundred percent of the federal poverty level.

A waiting period during which an individual is ineligible due to having dropped group health coverage. No

If the state elects to offer dental only supplemental coverage, the following assurances apply:

The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

The waiting period does not apply to children eligible for dental only supplemental coverage.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20140415

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SPA #: MO-14-0020 Approval Date: Effective Date: September 1, 2014 Page 2 of 2

cms CHIP Eligibility

State Name:|Missouri OMB Control Number: 0938-1148 Transmittal Number: 14 - 00-0020 Separate Child H | Non-Financei:

Expiration date: 10/31/2014

=

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes

Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes

Does the state have a premium lock out period? Yes

Please describe the lock-out period:

The individual is ineligible for a 90 day period if they fail to pay a premium after coverage begins..

What is the length of the time premium lock-out period? Select a length of time: C One month

C Two months @ 90 days

C Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

[1 Individual's income decreased to a level where no premium is required or within Medicaid standards (1) Other financial hardship &X] Other

Describe

+ Household income is less than 225% FPL. 4

The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3): and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

NOV 1 8 2015

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Page 1 of 2

coms CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20140415

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SPA #: MO-14-0020 Approval Date: Effective Date: September 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Missouri State Plan Amendments (SPA) #: MO-18-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01.-1.6 Baltinrore, MD 21244-1850 crvrs ctNÌHrs fora M¡DtcAnt & Mtt ¡cAtD stf,vtcrs CENTTß fON MEDICA¡D & CHIP SERVICFS Children and Adults Health Programs Group il|AR 2 I z0t9 Todd Richardson, Director MO HealthNet Division State of Missouri, Department of Social Services 615 Howerton Court, PO Box 6500 Jefferson City, MO 65102 Dear Mr. Richardson Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) MO- 1 8-001 5, submitted to the Centers for Medicare & Medicaid Services (CMS) on June 29,2018 with additional information submitted on March 11,2019, has been approved. Through this SPA, Missouri implements mental health parity requirements to ensure that treatment limitations applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. This SPA has an effective date of July 1, 2017 withthe exception of the changes highlighted below. Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that financial requirements and treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with the mental health parity requirements of 2705(a) of the Public Health Service Act, in the same manner in that such requirements apply to a group health plan. Missouri demonstrated compliance by providing the necessary assurances and supporting documentation that the state's application of non- quantitative treatment limitations (NQTLs) to MH/SUD benefits are consistent with section 2103(cX7)(A) of the Act. ln order to comply with CHIP parity requirements, Missouri is making the following policy changes related to NQTLs applicable to MH/SUD benefits: The state revised prior authorization policies in the fee-for-service (FFS) delivery system to reduce the number of services that require prior authorization. However, the state needed to make systems changes to fully implement this policy. The state is expecting to implement these system modifications by April 14,2019. The state identified documentation requirements that were only applicable to behavioral health providers and intends to address the issue by no later than May 30, 2019, following state regulatory changes. a This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analy zed separately.

Page2- Mr. Todd Richardson Your title XXI project officer is Ms. Kristin Edwards. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Edwards' contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: 52-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (a10) 786-5480 E-mail: kristin.edwards@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Edwards and to Mr. James Scott, Associate Regional Administrator (ARA) in our Kansas City Regional Office. Mr. Scott's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Richard Bolling Federal Building 601 East 12th Street, Room 355 Kansas City, MO 64106-2808 If you have additional questions, please contact Ms. Amy Ltttzky, Director, Division of State Coverage Programs at (410) 786-0721. We look forward to continuing to work with you and your staff. Sincerely, Director Enclosure cc: Mr. James Scott, Associate Regional Administrator, RegronVII, Kansas City /signed Anne Marie Costello/

Missouri Application for the State Children’s Health Insurance Program

Effective Date: July 1, 2017 Approval Date: Bold Italics Added Information Prior Approval Date: May 18, 2017 Strikethrough Deleted Information

- 5 -

1.4 Effective Dates

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment. (42 CFR 457.65) Effective date (date State incurs costs): Initial Combination SCHIP State Plan Submission, SPA #3: September 1, 2007 SPA #4: Disapproved December 19, 2008 SPA #5: Effective May 1, 2009 SPA #6: Effective July 1, 2009 SPA #7: Withdrawn June 29, 2011 SPA #8: Effective July 1, 2011 MO-15-0009-CHIP: Effective January 1, 2016 MO-15-0010: Effective January 1, 2016 MO-15-0011: Effective January 1, 2016 MO-17-002: Effective May 1, 2017 MO-18-0015: Effective July 1, 2017 Implementation date (date services begin): SPA #3: September 1, 2007 SPA #4: Disapproved December 19, 2008 SPA #5: May 1, 2009 SPA #6: July 1, 2009 SPA #7: Withdrawn June 29, 2011 SPA #8: Effective July 1, 2011 MO-15-0009-CHIP: Effective January 1, 2016 MO-15-0010: Effective January 1, 2016 MO-15-0011: Effective January 1, 2016 MO-17-002: Effective May 1, 2017 MO-18-0015: Effective July 1, 2017

Effective Date: July 1, 2017 Approval Date: Bold Italics Added Information Prior Approval Date: May 18, 2017 Strikethrough Deleted Information - 39 -

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines Response: Please see the Missouri’s MHPAEA Report for the Centers for Medicare & Medicaid Services, Section IV, Definition of MH/SUD and M/S Benefit for a description of the use of the State’s Medicaid Manual. This report is enclosed.

Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No Guidance: If the State does not provide any mental health or substance use

Effective Date: July 1, 2017 Approval Date: Bold Italics Added Information Prior Approval Date: May 18, 2017 Strikethrough Deleted Information - 40 -

disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes X No Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

Response: Missouri has a combination CHIP program consisting of an expansion CHIP population and a separate CHIP population. Only the separate CHIP population is included in this response since the expansion CHIP population is subject to Medicaid regulations that do not provide for deemed compliance with parity by providing EPSDT. Missouri’s separate CHIP population does not receive a full EPSDT benefit since they do not receive NEMT benefits.

Effective Date: July 1, 2017 Approval Date: Bold Italics Added Information Prior Approval Date: May 18, 2017 Strikethrough Deleted Information - 41 -

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan.

A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements. Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3- MHPAEA must be completed as well as the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

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Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A))

Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

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Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

Response: Please see Missouri’s MHPAEA Report for the Centers for Medicare & Medicaid Services, Section V, Benefit Classification for a description of the standards used to place covered benefits into one of the four classifications. This report is enclosed.

6.2.3.1.1 MHPAEA The State assures that:

The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub-

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classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

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Yes (Type(s) of limit: ) X No Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one-third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual

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dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one- third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one- third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5-MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

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The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits.

Quantitative Treatment Limitations

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non-quantitative treatment limitations.

6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a

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type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as

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compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one-half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification.

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Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

Response: Please see Missouri’s MHPAEA Report for the Centers for Medicare & Medicaid Services, Section VIII, Non-Quantitative Treatment Limitations, Appendix 1, Benefit Package and Classification Grid, and Appendix 2, NQTL Determination. This report is enclosed.

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of- network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgical benefits provided by out-of-network providers?

Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information

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6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both Other

Guidance: If other is selected, please specify the entity.

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information:

State Managed Care entities Both

Other

Guidance: If other is selected, please specify the entity. 6.3. The State assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42 CFR 457.480)

6.3.1.

The State shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA. (Formerly 8.6.) (Section 2103(f)) Describe:

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Guidance: States may request two additional purchase options in Title XXI: cost effective coverage through a community-based health delivery system and for the purchase of family coverage. (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4. Additional Purchase Options- If the State wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the State must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage- Payment may be made to a State in excess of the 10 percent limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the State to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The State may cross reference Section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42 CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42 CFR 457.1005(b))

Guidance: Check below if the State is requesting to provide cost-effective coverage through a community-based health delivery system. This allows the State to waive the 10 percent limitation on expenditures not used for Medicaid or health insurance assistance if coverage provided to targeted low-income children through such expenditures meets the requirements of Section 2103; the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under Section 2103; and such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Services Act or with hospitals such as those that

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receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923.

If the cost-effective alternative waiver is requested, the State must demonstrate that payments in excess of the 10 percent limitation will be used for other child health assistance for targeted low- income children; expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and other reasonable costs incurred by the State to administer the plan. (42 CFR, 457.1005(a))

6.4.1.3. The coverage must be provided through the use of a community based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42 CFR 457.1005(a))

Guidance: Check 6.4.2.if the State is requesting to purchase family coverage. Any State requesting to purchase such coverage will need to include information that establishes to the Secretary’s satisfaction that: 1) when compared to the amount of money that would have been paid to cover only the children involved with a comparable package, the purchase of family coverage is cost effective; and 2) the purchase of family coverage is not a substitution for coverage already being provided to the child. (Section 2105(c)(3)) (42 CFR 457.1010)

6.4.2.

Purchase of Family Coverage- Describe the plan to purchase family coverage. Payment may be made to a State for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42 CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective. The State’s cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its

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demonstration of cost effectiveness on an assessment of the cost of coverage, including administrative costs, for children or families under premium assistance programs to the cost of other CHIP coverage for these children or families, done on a case-by-case basis, or on the cost of premium assisted coverage in the aggregate.

6.4.2.2. The State assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42 CFR 457.1010(b))

6.4.2.3. The State assures that the coverage for the family otherwise meets title XXI requirements. (42 CFR 457.1010(c))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO # 10-002 issued February, 2, 2010) A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)). Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low-income children?

Yes

No

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan.

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6.4.3.2.1-PA If the State is providing premium assistance for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low- income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits.

6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F).

6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)).

6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

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6.4.3.5-PA Purchasing Pool- A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option?

Yes

No

6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)).

6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

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Section 8. Cost-Sharing and Payment

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 9.

8.4. The State assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42 CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42 CFR 457.520) 8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42 CFR 457.515(f))

8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify: ) No Guidance: For the purposes of parity, financial requirements include deductibles, copayments, coinsurance, and out of pocket maximums; premiums are excluded from the definition. If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial requirements. If the state does apply financial requirements to mental health or substance use

Effective Date: July 1, 2017 Approval Date: Bold Italics Added Information Prior Approval Date: May 18, 2017 Strikethrough Deleted Information - 57 -

disorder benefits, the state must conduct a parity analysis. Please continue below.

Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2.

8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits?

Yes No Guidance: If the State does not apply financial requirements on any medical/surgical benefits, the State may not impose financial requirements on mental health or substance use disorder benefits.

8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the class which are subject to the limitation.

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within which the State applies financial requirements to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results of the parity analysis as an attachment to the State child health plan.

8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of financial requirement to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose financial requirements on mental health or substance use disorder benefits in that classification. (42 CFR

Effective Date: July 1, 2017 Approval Date: Bold Italics Added Information Prior Approval Date: May 18, 2017 Strikethrough Deleted Information - 58 -

457.496(d)(3)(i)(A))

8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

8.5. Describe how the State will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the State for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

TODD RICHARDSON, DIRECTOR MO HEALTHNET DIVISION P.O. BOX 6500 • JEFFERSON CITY, MO 65102-6500 WWW.DSS.MO.GOV • 573-751-3425

1 | P a g e MHPAEA REPORT FOR CMS – Updated 12/04/2018

MICHAEL L. PARSON, GOVERNOR • STEVE CORSI, Psy.D., DIRECTOR

M H P A E A R E P O R T F O R T H E C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S I . I N T R O D U C T I O N The Centers for Medicare & Medicaid Services (CMS) issued a final rule that applies requirements of the Mental Health Parity and Addiction Equity Act (MHPAEA) to Medicaid managed care organizations (MCOs), the Children’s Health Insurance Program (CHIP), and Medicaid alternative benefit plans (ABPs). The purpose of the rule is to strengthen access to mental health and substance use disorder services for Medicaid participants. The rule applied parity requirements to Medicaid managed care organizations, alternative benefit plans, and the Children’s Health Insurance Program (CHIP). Specific requirements included:  Aggregate lifetime and annual dollar limits;  Financial requirements (FR);  Quantitative treatment limitations (QTLs);  Non-quantitative treatment limitations (NQTLs); and  Information requirements. In essence, the parity rule ensures that limitations on mental health and substance use disorder (MH/SUD) services are not more restrictive than limitations on medical/surgical (M/S) services. Aggregate lifetime and annual dollar limits are limits on the total dollar amount a Medicaid program will pay for specified benefits over a beneficiary’s lifetime or on an annual basis. These limits cannot be applied to (MH/SUD) benefits unless they apply to at least one third of all (M/S) benefits. In addition, limits must either be applied to both M/S and MH/SUD benefits as a whole or the limits applicable to MH/SUD benefits must be no more restrictive than those for M/S benefits. FRs and QTLs for MH/SUD benefits within a classification may not be more restrictive than the predominant FR or QTL applicable to substantially all medical/surgical benefits in that classification.

A non-quantitative treatment limitation (NQTL) may not apply to MH/SUD benefits in a classification unless, under the policies and procedures as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits in the classification are comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the NQTL to M/S benefits in the classification. Further, the Parity Rule added requirements to make certain information pertaining to mental health and substance use disorder benefits available, specifically the criteria for medical necessity determinations and reason for denial of reimbursement or payment. Missouri (State) and its contracted Medicaid/CHIP Health Plans were required to be in compliance with the final Medicaid/CHIP parity rule on or before October 2, 2017. Missouri requested an extension of this

2 | P a g e MHPAEA REPORT FOR CMS

compliance deadline, and CMS indicated they would not proactively enforce the compliance deadline and offered technical assistance. This report demonstrates the State of Missouri’s compliance with the parity requirements in 42 CFR Part 438 related to MCOs (referred to as Health Plans in Missouri). Since the Health Plans provide services to both Medicaid and CHIP beneficiaries, this report addresses both Medicaid and CHIP. Information on parity compliance for CHIP beneficiaries will also be provided as part of the CHIP state plan amendment. Missouri does not have an ABP, so those requirements do not apply. This report reflects work by the State and its Health Plans to conduct a review of the State’s Medicaid/CHIP delivery system to assess compliance with the final Medicaid/CHIP parity rule. The State staff participating in the parity assessment included representatives from the following State agencies: • The Missouri HealthNet Division (MHD) under the Missouri Department of Social Services • The Division of Behavioral Health (DBH) under the Department of Mental Health • The Division of Developmental Disabilities (DoDD) under the Department of Mental Health I I . M E T H O D O L O G Y The approach and results of each component of the analysis are discussed in detail in later sections of this report. Missouri’s approach to conducting the parity analysis followed CMS guidance as outlined in the CMS parity toolkit, “Parity Compliance Toolkit Applying Mental Health and Substance Use Disorder Parity Requirements to Medicaid and Children’s Health Insurance Programs”1 and included the following steps: 1. Identifying all benefit packages to which parity applies. 2. Determining whether the State or MCO is responsible for the parity analysis (by benefit package). 3. Defining mental health (MH), substance use disorder (SUD), and medical/surgical (M/S) benefits and determining which covered benefits are MH, SUD, and/or M/S benefits. 4. Defining the four benefit classifications (inpatient, outpatient, prescription drugs, and emergency care) and mapping MH/SUD and M/S benefits to these classifications. 5. Determining whether any aggregate lifetime or annual dollar limits (AL/ADLs) apply to MH/SUD benefits. 6. Determining whether any financial requirements (FRs) or quantitative treatment limitations (QTLs) apply to MH/SUD benefits and testing the applicable FRs or QTLs for compliance with parity. 7. Identifying and analyzing non-quantitative treatment limitations (NQTLs) that apply to MH/SUD benefits. I I I . M E D I C A I D / C H I P D E L I V E R Y S Y S T E M A N D B E N E F I T P A C K A G E S Medicaid/CHIP Delivery System Missouri operates a mandatory capitated managed care program for certain Medicaid beneficiaries and all CHIP beneficiaries. Managed care in Missouri was implemented in 1995 for certain regions of Missouri and requires certain Medicaid populations (TANF, pregnant women, and foster care) and CHIP beneficiaries to receive acute physical and limited behavioral health services through a Health Plan. Missouri’s Medicaid/CHIP managed care program, operated by MHD, is authorized under the authority of a 1915(b) waiver. On May 1, 2017, Missouri extended coverage statewide for the same populations previously covered under managed care. For covered Medicaid populations and CHIP children, nearly all beneficiaries are enrolled in managed care.

1 Parity Compliance Toolkit Applying Mental Health and Substance Use Disorder Parity Requirements to Medicaid and Children’s Health Insurance Programs, https://www.medicaid.gov/medicaid/benefits/downloads/bhs/parity- toolkit.pdf

3 | P a g e MHPAEA REPORT FOR CMS

MHD currently contracts with three Health Plans to serve Medicaid/CHIP beneficiaries: Home State Health, Missouri Care, and United Healthcare Community Health Plan. Certain services, including pharmacy and the majority of MH/SUD benefits, are provided fee-for-service (FFS). For most populations, the Health Plans provide limited MH/SUD coverage, and the remaining MH/SUD benefits are covered by DMH. For Foster Children (see Table 1), all MH/SUD benefits are covered FFS, with certain MH/SUD benefits managed by MHD and others by DMH. Benefit Packages Missouri identified eight benefit packages subject to the requirements in the final Medicaid/CHIP parity rule. See Appendix 1 for detailed information on the benefit packages, including the MH, SUD, and M/S benefits by classification. For each benefit package, Missouri covers MH and SUD benefits in each classification in which there is an M/S benefit (all four benefit classifications). T A B L E 1 – B E N E F I T P A C K A G E S Benefit Package Name Eligibility Groups Adults (Ages 21+) • Medical Assistance (MA) for Families • Transitional MA • Refugee Assistance Pregnant Women (Ages 21+) • Pregnant Women CHIP – Separate (<19)1 • CHIP Kids Foster Children (FC) – Outside Jackson County (JC) (<21) • State Custody • Foster Care • Adoption Subsidy • Juvenile Courts FC – Outside JC (21-25) FC – JC (<21) FC – JC (21-25) Other Children • Medical Assistance (MA) for Families • Transitional MA • MO HealthNet for Newborns • Refugee Assistance • Pregnant Women (<21) • CHIP Expansion* 1Note that effective September 1, 2007, CMS approved Missouri’s request for a combination CHIP. The CHIP combination program is comprised of a Medicaid Expansion and a Separate Child Health Insurance Program. For purposes of the parity analysis, the Separate Child Health Insurance Program (CHIP Separate) was not included under Other Children since it does not cover non-emergency medical transportation (NEMT). I V . D E F I N I T I O N O F M H / S U D A N D M / S B E N E F I T S For purposes of the parity analysis, Missouri adopted the most recent version of the International Classification of Diseases (ICD), the ICD-10-CM, as its standard for defining MH/SUD and M/S benefits. ICD-10-CM is the current version of the ICD, which is identified in the final Medicaid/CHIP parity rule as an example of a “generally recognized independent standard of current medical practice” for defining M/S, MH, and SUD conditions.

4 | P a g e MHPAEA REPORT FOR CMS

Missouri defined MH/SUD conditions as those conditions listed in ICD-10-CM, Chapter 5 “Mental, Behavioral, and Neurodevelopmental Disorders” with the exception of: • Conditions listed in subchapter 1, “Mental disorders due to known physiological conditions” (F01 to F09); • Conditions listed in subchapter 8, “Intellectual disabilities” (F70 to F79); and • Conditions listed in subchapter 9, “Pervasive and specific developmental disorders” (F80 to F89). Missouri defined M/S conditions as those conditions listed in ICD-10-CM Chapters 1-4, subchapters 1, 8 and 9 of Chapter 5, and Chapters 6-20. Missouri excluded subchapter 1 from the definition of MH/SUD because these mental disorders are due to known physiological conditions (e.g., vascular dementia, delirium due to known physiological conditions) and all except one require that the physiological condition be coded first, indicating that the physiological (rather than the MH) condition is the focus of services. Missouri excluded subchapters 8 and 9 from the definition of MH/SUD because these chapters identify neurodevelopmental disorders as opposed to mental or behavioral disorders. Excluding subchapters 8 (intellectual disabilities) and 9 (developmental disorders) from the definition of MH/SUD is consistent with the State’s current structure and practice. Services for these conditions are managed by DoDD, not by MHD or DBH. In addition, not including these disorders as MH/SUD disorders is consistent with CMS’ definition of “mental disease,” in the State Medicaid Manual (SMM) Section 4390.D, which provides as follows: “…the term ‘mental disease’ includes diseases listed as mental disorders in the [ICD-9-CM], with the exception of mental retardation, senility, and organic brain syndrome.”2 Also, not including F70 to F79 (intellectual disabilities) and F80 to F89 (pervasive and specific developmental disorders) is consistent with the definition of “Persons with related conditions” in 42 CFR 435.1010: “Persons with related conditions means individuals who have a severe, chronic disability that meets all of the following conditions: (a) It is attributable to (1) Cerebral palsy or epilepsy; or (2) Any other condition, other than mental illness, found to be closely related to Intellectual Disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons…” (sections (b) through (d) omitted; emphasis supplied).3 V . B E N E F I T C L A S S I F I C A T I O N S Missouri developed the following definitions for each of the four benefit classifications identified in the Medicaid/CHIP parity rule. Inpatient: All covered services or items (including medications) provided to a beneficiary in a setting for which the State pays room and board. Outpatient: All covered services or items (including medications) provided to a beneficiary that do not otherwise meet the definition of inpatient, emergency care, or prescription drugs.

Emergency Care: All covered services or items (including medications) delivered in an emergency department setting.

2 State Medicaid Manual – Part 4 Services, https://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R74SMM.pdf 3 42 CFR § 435.1010 - DEFINITIONS RELATING TO INSTITUTIONAL STATUS, https://www.gpo.gov/fdsys/pkg/CFR-2015-title42-vol4/xml/CFR-2015-title42-vol4-sec435-1010.xml

5 | P a g e MHPAEA REPORT FOR CMS

Prescription Drugs: Covered medications, drugs and associated supplies that require a prescription for use in an outpatient setting and other services delivered by pharmacist who works in a free-standing pharmacy. As noted above, Missouri’s state plan covers MH and SUD benefits in each classification in which there is a M/S benefit. See Appendix 1 for a mapping of MH/SUD and M/S benefits to each classification. V I . A G G R E G A T E L I F E T I M E A N D A N N U A L D O L L A R L I M I T S ( A L / A D L S ) No aggregate lifetime or annual dollar limits apply to Medicaid/CHIP MH/SUD benefits in any benefit package. V I I . F I N A N C I A L R E Q U I R E M E N T S ( F R S ) A N D Q U A N T I T A T I V E T R E A T M E N T L I M I T A T I O N S ( Q T L S ) Financial Requirements Inpatient, Outpatient, and Emergency Care Benefits For Health Plan enrollees, no financial requirements apply to Medicaid/CHIP MH/SUD benefits in any benefit package for the Inpatient, Outpatient, and Emergency Care benefit classifications. Prescription Drug Benefits The Prescription Drug benefits are administered by the State and are not the financial responsibility of the Health Plans. A tiered copayment for prescription drugs applies to Medicaid/CHIP benefits. Missouri’s tiered copayment for prescription drugs is based on the Medicaid cost/payment for the drug. This tiered copayment applies to all prescription drugs and, since the benefit is administered by the State, to both Medicaid FFS beneficiaries and Health Plan enrollees. See below for the copayment schedule. The copayment amount is based on the Medicaid payment for the drug and not whether the drug is used for the treatment of a MH/SUD or M/S condition, and the same level of copayment is applied across each tier without regard to whether the drug is for the treatment of a MH/SUD or M/S condition. TABLE 2 – PRESCRIPTION DRUG TIERED COPAYMENTS Medicaid Payment for the Drug Copayment $10.00 or less $.50 $10.01 to $25.00 $1.00 $25.01 to $50.00 $2.00 $50.01 or more $3.00

Quantitative Treatment Limitations Missouri does not apply any quantitative treatment limitations to MH/SUD benefits that cannot be exceeded based on medical necessity. Thus, these limitations were analyzed as NQTLs (see Section VIII of this report). V I I I . N O N - Q U A N T I T A T I V E T R E A T M E N T L I M I T A T I O N S ( N Q T L S ) Missouri identified a list of potential NQTLs through a workgroup process using the following sources: • Illustrative list of NQTLs in the final Medicaid/parity rule • MHPAEA parity toolkit

6 | P a g e MHPAEA REPORT FOR CMS

• Written guidance from the Department of Labor regarding the commercial parity rule (including FAQs, MHPAEA enforcement updates, and a document identifying potential “red flag” NQTLs) • Information from the State’s consultant • Internal discussion Additionally, the State developed a request for information (RFI) for each agency to complete with information needed to conduct the NQTL analysis. The RFI required information on the processes, strategies, and evidentiary standards in both writing and operations for each of the NQTLs the agency applies to MH/SUD benefits managed by the state agency. The information was further detailed by classification and benefit package. This RFI included prompts to help identify the type of information relevant to the parity analysis. Separate prompts were provided for processes, strategies, and evidentiary standards for each part of the NQTL analysis (comparability and stringency) and to collect information on how the factors apply both in writing and in operation. In addition to collecting information on NQTLs that apply to MH/SUD benefits managed by the State (referenced as the FFS MH/SUD NQTLs), the State developed an additional request for information (RFI) to collect information from each Health Plan. The RFI required information on how the Health Plan applies the FFS NQTLs to MH/SUD and M/S benefits managed by the Health Plan as well as any additional NQTLs applied by the MCOs to MH/SUD benefits (including information on how the Health Plan applies those NQTLs to M/S benefits). The RFI included the list of NQTLs identified by the State as described above but also asked the Health Plans to identify any other NQTLs that they apply to MH/SUD benefits. The Health Plans completed a summary grid that identified which FFS MH/SUD NQTLs and other NQTLs they apply to MH/SUD benefits, by benefit package and classification, and provided information, by benefit package and classification, on the MH/SUD and M/S benefits to which the NQTL applies and the processes, strategies, and evidentiary standards for each of the NQTLs. As in the State RFI, the Health Plan RFI included prompts to help the Health Plans provide the information needed for the parity analysis. The information provided by each Health Plan was reviewed by the State, and the State conducted follow up as needed. The State used the information from the RFIs to compare the processes, strategies, evidentiary standards and other factors for each MH/SUD NQTL as it applies to MH/SUD benefits and M/S benefits, in writing and in operation, in a classification, for each benefit package. The processes, strategies, evidentiary standards and other factors were reviewed for comparability and stringency in writing and in operation. Tables 3-5 lists the NQTLs that apply to MH/SUD benefits and the State has determined comply with parity. The table also identifies the applicable benefit package groups and classification. In the tables below, a “” indicates the NQTL applies to a certain benefit package(s) and classification(s). Grayed out sections in the tables below indicate the NQTL does not apply to a certain benefit package or classification. Additional information on each NQTL and how each NQTL meets parity requirements is included in Appendix 2, described below.

Page 7

7 | P a g e MHPAEA REPORT FOR CMS – Updated 12/04/2018

T A B L E 3 – N Q T L S – H O M E S T A T E H E A L T H NQTL Name Adults Pregnant Women CHIP— Separate FC – JC (<21) FC – JC (21- 25) FC - Outside JC (<21) FC - Outside JC (21-25) Other Children

IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD Prior Authorization* / Concurrent Review* / Retrospective Review  

  

  

  

  

  

  

  

 Step Therapy/Fail First Requirements*















 Documentation Requirements*  

 

 

 

 

 

 

 

Development/ Modification/ Addition of Medical Necessity/ Medical Appropriateness/ Level of Care Guidelines* and Experimental/ Investigational Determinations  

 

 

 

 

 

 

 

Network Admission Requirements – Provider Enrollment and Credentialing*  

 

 

 

 

 

 

 

Provider Type Exclusions*  

 

 

 

 

 

 

 

Provider Reimbursement* / Usual, Customary and Reasonable (UCR) Determinations (out-of- network provider reimbursement)*  

  

  

  

  

  

  

  

 Geographic Restrictions* / Travel Time/Distance Requirements* / Standards for Out-of-Network Coverage*  

 

 

 

 

 

 

 

Drugs not Covered Pursuant to Section 1927(d)(2)















 Early Refills















 Tiered Copayments















 *Applies to FFS MH/SUD IP=Inpatient, OP=Outpatient, EC=Emergency Care, PD=Prescription Drugs

8 | P a g e MHPAEA REPORT FOR CMS

T A B L E 4 – N Q T L S – M I S S O U R I C A R E NQTL Name Adults Pregnant Women CHIP— Separate FC – JC (<21) FC – JC (21- 25) FC - Outside JC (<21) FC - Outside JC (21-25) Other Children

IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD Prior Authorization* / Concurrent Review* / Retrospective Review  

  

  

  

  

  

  

  

 Documentation Requirements*  

 

 

 

 

 

 

 

Development/ Modification/ Addition of Medical Necessity/ Medical Appropriateness/ Level of Care Guidelines* and Experimental/ Investigational Determinations  

 

 

 

 

 

 

 

Network Admission Requirements – Provider Enrollment and Credentialing*  

 

 

 

 

 

 

 

Provider Type Exclusions*  

 

 

 

 

 

 

 

Provider Reimbursement* / Usual, Customary and Reasonable (UCR) Determinations (out-of- network provider reimbursement)*                                 Geographic Restrictions* / Travel Time/Distance Requirements* / Standards for Out-of-Network Coverage*  

 

 

 

 

 

 

 

Drugs not Covered Pursuant to Section 1927(d)(2)















 Early Refills















 Tiered Copayments















 *Applies to FFS MH/SUD IP=Inpatient, OP=Outpatient, EC=Emergency Care, PD=Prescription Drugs

9 | P a g e MHPAEA REPORT FOR CMS

T A B L E 4 – N Q T L S – U N I T E D H E A L T H C A R E NQTL Name Adults Pregnant Women CHIP— Separate FC – JC (<21) FC – JC (21- 25) FC - Outside JC (<21) FC - Outside JC (21-25) Other Children

IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD IP OP EC PD Prior Authorization* / Concurrent Review* / Retrospective Review  

  

  

  

  

  

  

  

 Outlier Review   

  

  

  

  

  

  

  

Documentation Requirements*  

 

 

 

 

 

 

 

Development/ Modification/ Addition of Medical Necessity/ Medical Appropriateness/ Level of Care Guidelines* and Experimental/ Investigational Determinations  

 

 

 

 

 

 

 

Network Admission Requirements – Provider Enrollment and Credentialing*   

  

  

  

  

  

  

  

Provider Type Exclusions*  

 

 

 

 

 

 

 

Provider Reimbursement* / Usual, Customary and Reasonable (UCR) Determinations (out-of- network provider reimbursement)*                                 Geographic Restrictions* / Travel Time/Distance Requirements* / Standards for Out-of-Network Coverage*   

  

  

  

  

  

  

  

Drugs not Covered Pursuant to Section 1927(d)(2)















 Early Refills















 Tiered Copayments















 *Applies to FFS MH/SUD IP=Inpatient, OP=Outpatient, EC=Emergency Care, PD=Prescription Drugs

10 | P a g e MHPAEA REPORT FOR CMS

A P P E N D I X 1 — B E N E F I T P A C K A G E A N D C L A S S I F I C A T I O N G R I D Benefit MH/SUD or M/S Benefit Benefit Classific ation1 Adults Pregnant Women CHIP— Separate FC – JC (<21) FC – JC (21-25) FC - Outside JC (<21) FC - Outside JC (21- 25) Other Children Health Plan Benefit Package

Ambulance (emergency only) Both EC         Ambulatory Surgical Care M/S OP         Birthing Center M/S OP         Certified Nurse Practitioners Both OP         Comprehensive Day Rehabilitation M/S OP

       Dental Services M/S OP         Dentures M/S OP

       Diabetes Self-Management Training M/S OP

       Durable Medical Equipment M/S OP         Emergency Medical, BH and SA Services, and Post- Stabilization Services Both EC         Family Planning Services M/S IP/OP         Healthy Children and Youth program (i.e., EPSDT) Both OP

 



 Hearing Aids (Audiology) M/S OP

       Home Health Services M/S OP         Hospice Services M/S IP/OP         Inpatient Hospital Services Both IP         Laboratory and X-ray services Both OP         Non-Emergency Medical Transportation Both OP  

     Nurse midwife M/S OP         Optical M/S OP         Orthodontics M/S OP

      Outpatient Hospital Services Both OP         Personal Care Both OP         Physician/Advanced Practice Nurse Services/FQHC/RHC Both IP/OP         Podiatry Services M/S OP        

11 | P a g e MHPAEA REPORT FOR CMS

Benefit MH/SUD or M/S Benefit Benefit Classific ation1 Adults Pregnant Women CHIP— Separate FC – JC (<21) FC – JC (21-25) FC - Outside JC (<21) FC - Outside JC (21- 25) Other Children Private Duty Nursing M/S OP

      Psychologists MH/SUD OP    FFS FFS FFS FFS  Rehabilitation Services Both OP

      Social Workers/Counselors Both OP    FFS FFS FFS FFS  Targeted Case Management — HCY & Lead, Prenatal Both OP Prenatal Only Prenatal Only       Transplant Related Services (Pre-Transplant and Post-Transplant Services) M/S OP         FFS-Only Services

Applied Behavioral Analysis M/S OP

      Environmental Lead Assessment M/S OP

      ICF/MR M/S IP

   

Nursing Facility M/S IP

Pharmacy Both PD/OP2         Targeted Case Management (TCM) — Foster Care Both OP

 

TCM — SMI/SED and MRDD Both OP         Transplants M/S IP         Community Psych Rehab Services

- Assertive Community Treatment MH/SUD OP         - Co-Occurring Services MH/SUD OP         - Community Support MH/SUD OP         - Consultation Services MH/SUD OP         - Crisis Intervention and Resolution MH/SUD OP         - Day Treatment - Youth MH/SUD OP

 



 - Evidence Base Practices MH/SUD OP

 



 - Evaluation and Treatment Plans MH/SUD OP         - Family Assistance MH/SUD OP

 



 - Family Support MH/SUD OP

 



 - Individual and Group Professional PSR (Ages 5+) MH/SUD OP        

12 | P a g e MHPAEA REPORT FOR CMS

Benefit MH/SUD or M/S Benefit Benefit Classific ation1 Adults Pregnant Women CHIP— Separate FC – JC (<21) FC – JC (21-25) FC - Outside JC (<21) FC - Outside JC (21- 25) Other Children - Inpatient Diversion (Child & Adult) MH/SUD OP         - Intensive Community Psychiatric Rehab MH/SUD OP         - Medication Services MH/SUD OP         - Medication Administration MH/SUD PD/OP         - Metabolic Syndrome Screening MH/SUD OP         - Peer Support Services MH/SUD OP         - Professional Parent Home MH/SUD OP

 



 - Psychosocial Rehabilitation MH/SUD OP         - PSR Illness Management and Recovery MH/SUD OP         - School Based Services MH/SUD OP

 



 - Treatment Family Home MH/SUD OP

 



 Comprehensive Substance Treatment and Rehabilitation (CSTAR) Services

- Assessment and Diagnostic Testing MH/SUD OP         - Adolescent Treatment Support (Ages 12-17) MH/SUD OP

 



 - Collateral Dependent Counseling (Individual and Group) MH/SUD OP         - Communicable Disease Counseling MH/SUD OP         - Community Support MH/SUD OP         - Comprehensive Assessment MH/SUD OP         - Day Treatment MH/SUD OP         - Extended Day Treatment MH/SUD OP         - Family Therapy (Office and Home) MH/SUD OP         - Group Counseling MH/SUD OP         - Group Therapeutic Substance Use Education MH/SUD OP         - Individual Counseling MH/SUD OP         - Medically Monitored Inpatient Detoxification MH/SUD IP         - Medication Services MH/SUD OP         - Opioid Treatment Program MH/SUD PD/OP        

13 | P a g e MHPAEA REPORT FOR CMS

Benefit MH/SUD or M/S Benefit Benefit Classific ation1 Adults Pregnant Women CHIP— Separate FC – JC (<21) FC – JC (21-25) FC - Outside JC (<21) FC - Outside JC (21- 25) Other Children 1915(c) Home and Community Based Services Waivers

Adult Day Care Waiver (Ages 18–63) M/S OP  

     DD Comprehensive Waiver M/S OP  

     Division of DD Community Support Waiver M/S OP  

     Partnership for Hope M/S OP  

     1 IP=Inpatient, OP=Outpatient, EC=Emergency Care, PD=Prescription Drugs 2 Pharmacy benefits grouped in the Outpatient benefit classification include physician administered drugs.

14 | P a g e MHPAEA REPORT FOR CMS

A P P E N D I X 2 — N Q T L D E T E R M I N A T I O N The compliance analysis and determination for each NQTL, by benefit package and classification, is provided in this Appendix. The compliance analysis includes the MH/SUD and M/S benefits to which the NQTL applies; which entity (the Health Plan, MHD, DBH, or DoDD) manages the benefits; the parity analysis (comparability and stringency of the processes, strategies, evidentiary standards, and other factors used in applying the NQTL); and the compliance determination. Since both the State and the Health Plans administer MH/SUD benefits for all benefit packages except those for Foster Children, the analysis and compliance determination for the NQTLs that the State applies to FFS MH/SUD benefits (identified in Tables 3-5 of the narrative with an asterisk) for all benefit packages (except those for Foster Children) include information about both the State and Health Plan managed benefits.

15 | P a g e MHPAEA REPORT FOR CMS

NQTL: Prior Authorization (PA) / Concurrent Review (CR) / Retrospective Review (RR) Health Plan/State: Home State Health/Fee-for-Service Benefit Package(s): Adults (21+), Pregnant Women (21+), Children: COA 1 (0-20), PW (0-20), CHIP Exp. (0-18), and CHIP Separate (0-18), COA 4 if admission is for combination of physical and behavioral health Classification: Inpatient (IP) MH/SUD Benefits/Providers M/S Benefits/Providers Home State Health: IP MH, IP SUD FFS: N/A Home State: inpatient admissions M/S FFS: Transplant Compliance Analysis Both MH/SUD and M/S require PA for scheduled IP services. Emergency admissions and continued stays for both MH/SUD and M/S are subject to CR. RR applies when services have already been provided. Inpatient admissions are subject to authorizations since they are high cost and best practice is to treat in the least restrictive setting that meets the individual’s clinical needs. For both MH/SUD and M/S services, PA/CR facilitates better care coordination for the member and indicates to the HEALTH PLAN the need to assess for care management services.

MH/SUD and M/S PA and CR requests may be submitted by phone, fax, or web. MH/SUD RR requests are submitted by fax or mail; M/S RR requests may be submitted by fax, phone, or web. MH/SUD uses LOCUS/CALOCUS, as required by the state, as well as clinical policy guidelines. M/S uses Interqual guidelines and Centene clinical policies. For M/S, nonclinical and clinical staff review PA requests., and clinical staff review CR, and RR requests For MH/SUD, reviewers of PA, CR, and RR requests are licensed clinicians, as required by the state. For MH/SUD and for M/S denial rates are reviewed at least quarterly. Both MH/SUD and M/S require annual inter-rater reliability training/testing for utilization management staff and both require a 90% score. The timeframe for reviewing standard M/S PA requests is 36 hours to include one working day. Urgent M/S PA requests are completed within 24 hours. For MH/SUD PA reviews for scheduled admissions are completed within an hour of notification. For both MH/SUD and M/S, CR requests are completed within 24 hours. Nearly all MH/SUD inpatient admissions are emergent. For both MH/SUD and M/S requests for PA and CR, if the first reviewer is unable to approve, the second reviewer is a psychiatrist/physician, respectively. The provider and member have appeal rights in the event of an adverse determination. If the denial is upheld, members have the right to a state fair hearing, and providers can appeal to the administrative hearings commission.

PA / CR / RR requirements are reviewed and updated annually or as assigned by the state. For both MH/SUD and M/S, some facility contracts do not allow for RR. MH/SUD contracts allow for RR unless specifically excluded, but for M/S, contracts do not allow for RR unless specifically included, thus RR is less restrictive for MH/SUD as compared to M/S.

16 | P a g e MHPAEA REPORT FOR CMS

Transplant services are provided to health plan members through FFS. The transplant prior authorization process requires the transplant facility or transplant surgeon to submit documentation that verifies the transplant candidate has been evaluated according to the facility’s Patient Selection Protocol and Patient Selection Criteria for the type of transplant to be performed. The patient must have been accepted as a transplant candidate by the facility before prior authorization requests can be considered for approval by the MO HealthNet Division. Physician reviews request and if not approved by first reviewer, it is sent to second physician reviewer.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

☒ ☐ ☐

17 | P a g e MHPAEA REPORT FOR CMS

NQTL: Prior Authorization (PA) / Concurrent Review (CR) / Retrospective Review (RR) Health Plan/State: Home State Health, FFS Benefit Package(s): Category of Aid (COA) 4 (Ages 0-20), including ME 38 (ages 21-25), and foster children in and out of Jackson County Classification: Inpatient MH/SUD Benefits/Providers M/S Benefits/Providers Home State: N/A FFS: MH IP, SUD IP Home State: M/S IP FFS: Transplant Compliance Analysis Both MH/SUD (provided to health plan members through FFS) and M/S require PA for scheduled IP services. Emergency admissions and continued stays for both MH/SUD and M/S are subject to CR. RR applies when services have already been provided. Inpatient admissions are subject to authorizations since they are high cost and best practice is to treat in the least restrictive setting that meets the individual’s clinical needs. For M/S services, PA facilitates better care coordination for the member and indicates to the health plan the need to assess for care management services.

MH/SUD (provided to health plan members through FFS) PA and CR requests are by phone, fax, or online. MH/SUD RR requests are submitted by fax or mail. Conduent utilizes the Milliman Care Guidelines® screening criteria to establish a benchmark length of stay for all inpatient hospitalizations. Strategy: authorization is required for services that are high cost and/or have potential for overutilization. MH/SUD uses Milliman Care Guidelines (MCG). For MH/SUD, reviewers of PA, CR, and RR requests are LPNs and RNs. MH/SUD requires inter-rater reliability training of utilization management staff. For MH/SUD certifications meeting criteria, CONDUENT (FFS) expects to certify the admission at the time of the initial request when made via CyberAccess or telephone. MH/SUD Certifications meeting criteria when submitted by written or fax request will be made by the end of the next working day. For MH/SUD requests for PA and CR, if the first reviewer is unable to approve, the second reviewer is a psychiatrist. Members have the right to appeal to Conduent for fee-for-service benefits and the right to a state fair hearing if the denial is upheld by Conduent.. Providers can appeal to the health plan for health plan covered services and to Conduent for fee-for-service covered benefits and to the administrative hearings commission in the event of disagreement with the initial appeal response.

M/S PA and CR requests are by phone, fax, or online. M/S RR requests may be submitted by fax, phone, or web. M/S uses Interqual guidelines and Centene clinical policies. For M/S, nonclinical and clinical staff review PA, CR, and RR requests. M/S requires annual inter-rater reliability training/testing for utilization management staff. The timeframe for reviewing standard M/S PA requests is 36 hours to include one working day. Urgent M/S PA requests are completed within 24 hours. For M/S requests for PA and CR, if the first reviewer is unable to approve, the second reviewer is a physician. Members and providers have the same appeal rights for MH/SUD and M/S. Members have the right to the health plan appeal process for health plan covered services and

18 | P a g e MHPAEA REPORT FOR CMS

state fair hearing for health plan covered services (after exhausting the health plan appeal process). Members have the right to appeal to Conduent for fee- for-service benefits and the right to a state fair hearing if the denial is upheld by Conduent.. Providers can appeal to the health plan for health plan covered services and to Conduent for fee-for-service covered benefits and to the administrative hearings commission in the event of disagreement with the initial appeal response.

PA / CR / RR requirements are reviewed and updated annually or as assigned by the state. For MH/SUD, RR is available through Conduent. For M/S, some facility contracts do not allow RR.

Transplant services are provided to HEALTH PLAN members through FFS. The transplant prior authorization process requires the transplant facility or transplant surgeon to submit documentation that verifies the transplant candidate has been evaluated according to the facility’s Patient Selection Protocol and Patient Selection Criteria for the type of transplant to be performed. The patient must have been accepted as a transplant candidate by the facility before prior authorization requests can be considered for approval by the MO HealthNet Division. Physician reviews request and if not approved by first reviewer, it is sent to second physician reviewer.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

☒ ☐ ☐

19 | P a g e MHPAEA REPORT FOR CMS

NQTL: Prior Authorization (PA), Concurrent Review (CR), Retrospective Review Health Plan/State: Home State Health / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate Classification: Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Home State: MH/SUD IOP, PHP, ECT, MH/SUD provider specific contract FFS: CSTAR Home State: Home health services, pain management, non-emergent services with non-par providers, genetic testing, non-emergent CT scans, non-emergent MRI, dental procedures FFS: HCBS waiver services, ABA, abortion Compliance Analysis PA is required on selected MH/SUD outpatient services (e.g., IOP, PHP, ECT, specific contracts), but CR does not apply in the outpatient classification. Requests submitted by mail, fax, or web for MH/SUD services, but M/S service requests may be submitted by phone, fax, or web. Retrospective reviews are available for MH/SUD and M/S services if provider contract allows. MH/SUD contracts allow RR unless specifically excluded, whereas M/S contract do not allow RR unless specifically included. Clinical staff authorize PAs for MH/SUD services, but nonclinical and clinical staff authorize M/S PAs. Clarify role of nonclinical staff for M/S reviews. Evidence: use LOCUS/CALOCUS required by the state for MH/SUD services. For M/S services, InterQual criteria are used. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Timeliness of decision: 24 hours urgent, 36 hours routine for both MH/SUD and M/S services. IRR score required is 90% for both MH/SUD and M/S.If denied: provider and can appeal by phone, fax, or mail within 30 days; peer to peer review is offered; only physicians make adverse decisions for both MH/SUD and M/S services.

CSTAR – Authorization required when exceed dollar package limits for SUD services and exceed 60 days of adolescent treatment support program. PA is requested through DMH CIMOR system. Licensed or credentialed staff review PA requests. Clinical rationale for additional dollars for continuation of intensive services is required. Evidence: history of individuals exceeding package dollar limits. Practice guidelines include ASAM components. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Timeliness of decision: 36 hours to include one working day.

20 | P a g e MHPAEA REPORT FOR CMS

If denied: participant and provider have appeal rights within 30 days.

FFS M/S: All ABA services require PA. Requests are submitted by fax or by mail. Clinical documentation of medical necessity is required. Requests are reviewed by licensed behavior analyst. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Evidence: Missouri best practice guidelines and BACB best practice guidelines. Abortion services are limited by medical necessity in accordance with the Hyde Amendment. Requests are by fax or mail and are reviewed by RN and physician. HCBS waiver service require PA.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

☒ ☐ ☐

21 | P a g e MHPAEA REPORT FOR CMS

NQTL: Prior Authorization (PA), Concurrent Review (CR), Retrospective Review (RR) Health Plan/State: Home State Health / FFS / DMH Benefit Package(s): COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Home State: N/A – provided through FFS for this population FFS: outpatient therapy, psychological testing if under age 3, CSTAR Home State: Home health services, pain management, non- emergent services with non-par providers, genetic testing, non- emergent CT scans, non-emergent MRI, dental procedures FFS: HCBS waiver services, ABA, abortion

Compliance Analysis FFS MH/SUD (provided through FFS for this population) – PA required beyond 4 hours in a rolling year for family, group, or individual therapy and for psychological testing if under age 3. CR does not apply. RR applies only in the event of retroactive eligibility. PA is requested by phone, fax, mail, or online. Clinical staff authorize PAs. PA form requires diagnosis, demographics, service requested, and attestation regarding training in EBP if applicable, that services are developmentally appropriate if under 5, that patient/guardian has agreed to treatment plan, whether court ordered, communication with other providers, treatment plan provided to CD case manager if applicable, if result of an EPSDT screen. Evidence: history of overutilization and cost overruns. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Timeliness of decision: Decisions typically made same day; online decisions are immediate. If denied: participant has appeal rights within 90 days; provider has appeal rights within 30 days

CSTAR – Authorization required when dollar package limits for SUD services are exceeded and when adolescent treatment support exceeds 60 days. PA is requested through DMH CIMOR system and reviewed by licensed or credentialed staff. CR requests can be submitted by phone, fax, email, or mail. Clinical rationale for additional dollars for continuation of intensive services is required. The DBH also offers a specialized CSTAR Program solely to participants between the ages of 12 and 17 years inclusive (exceptions to age criteria may be authorized through the Clinical Utilization Review process) and their families.

22 | P a g e MHPAEA REPORT FOR CMS

Exceptions to these age requirements may be authorized through clinical utilization review documenting behavior and experience appropriate for the services available. Evidence: practice guidelines include ASAM components. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Review completed within 36 hours to include one working day. To the extent feasible, a review request from a provider shall be made prior to delivery of services. If denied: appeal must be in writing, identify the reason for the appeal, and be received or postmarked within thirty (30) days of receiving notice that service authorization has been discontinued.

HSH M/S: Request submitted by phone, fax, or web. Nonclinical and clinical staff utilized for PA reviews. Evidence: InterQual criteria are used. Strategy: authorization required for services that are high cost and/or have the potential for overutilization.. Timeliness of decision: 24 hours urgent, 36 hours routine. If denied: provider can appeal by phone, fax, or mail within 30 days; peer to peer review is offered; only physicians make adverse decisions.

FFS M/S: All ABA services require PA. Requests are submitted by fax or by mail. Clinical documentation of medical necessity is required. Requests are reviewed by licensed behavior analyst. Strategy authorization required for services that are high cost and/or have the potential for overutilization. Evidence: Missouri best practice guidelines and BACB best practice guidelines. Abortion services are limited by medical necessity in accordance with the Hyde Amendment. Requests are by fax or mail and are reviewed by RN and physician. HCBS waiver service require PA.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

State is reforming FFS policies to allow more services prior to authorization requirements. ☐

☒

☐

23 | P a g e MHPAEA REPORT FOR CMS

NQTL: Prior Authorization / Concurrent Review / Retrospective Review Health Plan/State: Missouri Care / FFS Benefit Package(s): Adults (21+), Pregnant Women (21+), Children: COA 1 (0-20), PW (0-20), CHIP Exp. (0-18), and CHIP Separate (0-18), COA 4 if admission is for combination of physical and behavioral health Classification: Inpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care: MH IP, SUD IP; Residential Treatment; FFS: N/A

Missouri Care: All IP FFS: Transplant Compliance Analysis Missouri Care does not require mental health/substance use disorder (MH/SUD) or medical/surgical (M/S) providers to obtain prior authorization (PA) for emergent inpatient admissions; notification of inpatient admission is required within 24 hours for both MH/SUD and M/S providers for CR. Residential treatment requires PA ahead of time (this is scheduled, not emergent). Scheduled inpatient M/S admissions require PA. RR applies when a member was admitted emergently and discharged from hospital prior to CR taking place. RR requests must be submitted within 90 days of discharge date for both MH/SUD and M/S. RR determinations are made within 30 calendar days. CR is completed every 1 to 2 days for continued stay for both MH/SUD and M/S services. Nationally recognized guidelines developed by third parties (LOCUS/CALOCUS, Interqual) are used for PA and CR to establish medical necessity for both MH/SUD and M/S services except that M/S utilizes WellCare Clinical Coverage Guidelines when WellCare medical directors have developed guidelines for the service requested. UM process and timeframes are the same for MH/SUD and M/S providers; if requested service does not meet medical necessity criteria, the clinical reviewer forwards to medical director for review; peer to peer conversation is offered in the event of adverse decisions. For MH/SUD and M/S, peer to peer conversation is offered in the event of adverse decision if requested within 3 days. For M/S considerations, reviewers are RNs or physicians, for MH/SUD considerations, reviewers are licensed clinicians or psychiatrists.

Evidence/rationale for applying PA, CR, and RR for both MH/SUD and M/S services is due to services that are high cost and/or have the potential for overutilization.

Transplant services are provided to health plan members through FFS. The transplant prior authorization process requires the transplant facility or transplant surgeon to submit documentation that verifies the transplant candidate has been evaluated according to the facility’s

24 | P a g e MHPAEA REPORT FOR CMS

Patient Selection Protocol and Patient Selection Criteria for the type of transplant to be performed. The patient must have been accepted as a transplant candidate by the facility before prior authorization requests can be considered for approval by the MO HealthNet Division. Physician reviews request and if not approved by first reviewer, it is sent to second physician reviewer.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Prior Authorization (PA) / Concurrent Review (CR) / Retrospective Review (RR) Health Plan/State: Missouri Care, FFS Benefit Package(s): Category of Aid (COA) 4 (Ages 0-20), including ME 38 (ages 21-25), and foster children in and out of Jackson County Classification: Inpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care: N/A FFS: MH IP, SUD IP Missouri Care: All IP FFS: Transplant Compliance Analysis Missouri Care does not require medical/surgical (M/S) providers to obtain prior authorization (PA) for emergent inpatient admissions; notification of inpatient admission is required within 24 hours for M/S providers. Interqual guidelines are used to establish medical necessity for M/S services except that M/S utilizes WellCare Clinical Coverage Guidelines when WellCare medical directors have developed guidelines for the service requested. Authorization requests are submitted via phone, fax, or secure email. Timeframe for decision is within 24 hours. Inter-rater reliability training is completed annually. Denial rates are reviewed at least monthly. Peer to peer conversation is offered if adverse decision is made. Second reviewer is a psychiatrist, and members and providers have appeal rights to health plan. After appeal to health plan, member may have state fair hearing. After appeal to health plan, provider may appeal to administrative hearings commission.

For MH/SUD (provided to health plan members through FFS), PA is not required for emergent admissions; certification review takes place after admission.MH/SUD PA and CR requests are by phone, fax, or online. MH/SUD RR requests are submitted by fax or mail. Conduent utilizes the Milliman Care Guidelines® screening criteria to establish a benchmark length of stay for all inpatient hospitalizations. Strategy: authorization is required for services that are high cost and/or have potential for overutilization. MH/SUD uses Milliman Care Guidelines (MCG). For MH/SUD, reviewers of PA, CR, and RR requests are LPNs and RNs. MH/SUD requires inter-rater reliability training of utilization management staff. For MH/SUD certifications meeting criteria, CONDUENT (FFS) expects to certify the admission at the time of the initial request when made via CyberAccess or telephone. MH/SUD Certifications meeting criteria when submitted by written or fax request will be made by the end of the next working day. For MH/SUD requests for PA and CR, if the first reviewer is unable to approve, the second reviewer is a psychiatrist. Members have the right to appeal to Conduent for fee-for-service benefits and the right to a state fair hearing if the denial is upheld by Conduent.. Providers can appeal to the health plan for health plan covered services and to Conduent for fee-for-service covered benefits and to the administrative hearings commission in the event of disagreement with the initial appeal response.

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Participants have the right to a state fair hearing for M/S.

Residential treatment may be accessed through Children’s Division referral process which uses the Childhood Severity of Psychiatric Illness (CSPI) completed by trained nonclinical CD staff.

Evidence/rationale for applying PA, CR, RR for M/S and MH/SUD is to ensure member is getting right level of care for their current condition and that they’re meeting medical necessity criteria.

Transplant services are provided to health plan members through FFS . The transplant prior authorization process requires the transplant facility or transplant surgeon to submit documentation that verifies the transplant candidate has been evaluated according to the facility’s Patient Selection Protocol and Patient Selection Criteria for the type of transplant to be performed. The patient must have been accepted as a transplant candidate by the facility before prior authorization requests can be considered for approval by the MO HealthNet Division.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Prior Authorization (PA), Concurrent Review (CR), Retrospective Review Health Plan/State: Missouri Care / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate Classification: Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care: MH/SUD IOP, PHP, OP that exceeds the applicable monthly or annual limit, short term residential (not covered by the Medicaid state plan), intensive in-home (not covered by the Medicaid state plan) FFS: CSTAR Missouri Care: ASC, comprehensive day rehab-TBI, certain diabetic care, certain diagnostic services, DME over $500, home health, hospice, infusion services, ICF, personal care, certain podiatry services, private duty nursing, prosthetic and orthotic devices over $500 FFS: ABA services

Compliance Analysis Missouri Care – PA required on selected MH/SUD services. CR is not utilized for MH/SUD in the outpatient classification. RR is not utilized for MH/SUD or M/S services in the outpatient classification. M/S PA requests are submitted via fax, web, or phone. MH/SUD PA requests are by fax, phone, or secure email. Clinical staff authorize PAs for both MH/SUD and M/S services. Evidence: MH/SUD services use LOCUS/CALOCUS required by the state,. Strategy: authorization required for services that are high cost and/or have the potential for overutilization . M/S services use InterQual criteria or WellCare Clinical Coverage Guidelines when they have been developed for the service requested. Timeliness of decision: 24 hours urgent, 36 hours routine for both MH/SUD and M/S services. For both MH/SUD and M/S services, if denied: peer to peer is offered; adverse determinations by physician only; member has appeal rights.

CSTAR – Authorization required when exceed dollar package limits for SUD services and exceed 60 days of adolescent treatment support program. PA is requested through DMH CIMOR system. Licensed or credentialed staff review PA requests. Clinical rationale for additional dollars for continuation of intensive services is required. Evidence: history of individuals exceeding package dollar limits. Practice guidelines include ASAM components.

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Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Timeliness of decision: 36 hours to include one working day. If denied: participant and provider have appeal rights within 30 days.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Prior Authorization (PA), Concurrent Review (CR), Retrospective Review (RR) Health Plan/State: Missouri Care / Missouri FFS / DMH Benefit Package(s): COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care: N/A – provided through FFS for this population FFS: outpatient therapy, psychological testing if under age 3, CSTAR

Missouri Care: ASC, comprehensive day rehab-TBI, certain diabetic care, certain diagnostic services, DME over $500, home health, hospice, infusion services, ICF, personal care, certain podiatry services, private duty nursing, prosthetic and orthotic devices over $500 FFS: HCBS waiver services, ABA, abortion

Compliance Analysis FFS MH/SUD (provided through FFS for this population) – PA required beyond 4 hours in a rolling year for family, group, or individual therapy and for psychological testing if under age 3. CR does not apply. RR applies only in the event of retroactive eligibility. PA is requested by phone, fax, mail, or online. Clinical staff authorize PAs. PA form requires diagnosis, demographics, service requested, and attestation regarding training in EBP if applicable, that services are developmentally appropriate if under 5, that patient/guardian has agreed to treatment plan, whether court ordered, communication with other providers, treatment plan provided to CD case manager if applicable, if result of an EPSDT screen. Evidence: history of overutilization and cost overruns. Strategy: authorization required for services that are high cost and/or have the potential for overutilization . Timeliness of decision: Decisions typically made same day; online decisions are immediate. If denied: participant has appeal rights within 90 days; provider has appeal rights within 30 days

CSTAR – Authorization required when dollar package limits for SUD services are exceeded and when adolescent treatment support exceeds 60 days. PA is requested through DMH CIMOR system and reviewed by licensed or credentialed staff. CR requests can be submitted by phone, fax, email, or mail. Clinical rationale for additional dollars for continuation of intensive services is required. The DBH also offers a specialized CSTAR Program solely to participants between the ages of 12 and 17 years inclusive (exceptions to age criteria may be authorized through the Clinical Utilization Review process) and their families.

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Exceptions to these age requirements may be authorized through clinical utilization review documenting behavior and experience appropriate for the services available. Evidence: practice guidelines include ASAM components. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Review completed within 36 hours to include one working day. To the extent feasible, a review request from a provider shall be made prior to delivery of services. If denied: appeal must be in writing, identify the reason for the appeal, and be received or postmarked within thirty (30) days of receiving notice that service authorization has been discontinued.

Missouri Care M/S – RNs review requests for PA. CR and RR are not utilized. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Evidence: use InterQual and WellCare coverage guidelines when they have been developed for the service requested. Timeliness of decision: 24 hours urgent, 36 hours routine. If denied: peer to peer is offered; adverse determinations by physician only; member has appeal rights.

FFS M/S: All ABA services require PA. Requests are submitted by fax or by mail. Clinical documentation of medical necessity is required. Requests are reviewed by licensed behavior analyst. Strategy is to ensure medical necessity of these time-intensive services. Evidence: Missouri best practice guidelines and BACB best practice guidelines. Abortion services are limited by medical necessity in accordance with the Hyde Amendment. Requests are by fax or mail and are reviewed by RN and physician. HCBS waiver services require PA.

State Compliance Determination Complies Follow up Doesn’t Comply Action: State is reforming FFS policies to allow more services prior to authorization requirements.

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NQTL: Prior Authorization (PA) / Concurrent Review (CR) / Retrospective Review (RR) Health Plan/State: UnitedHealthcare, FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate Classification: Inpatient MH/SUD Benefits/Providers M/S Benefits/Providers UHC: MH IP, MH SUD FFS: N/A UHC: M/S IP FFS: Transplant Compliance Analysis UnitedHealthcare - PA not required for MH/SUD or M/S inpatient admissions that are direct/emergent. M/S scheduled inpatient admissions require prior authorization. The process and timeframes described for both MH/SUD and M/S PA and CR are the same. MH/SUD and M/S requests are by phone, and, when available, clinical information can be provided via access to EMR; clinical information is required. Authorization is provided within 24 hours of receipt of the request for both MH/SUD and M/S. Peer to peer occurs within 3 business days of facility being notified of denial of inpatient level of care for MH/SUD and M/S. Only physicians make adverse determinations, and physician has 2 days to make a final determination. This is the same for MH/SUD and M/S. An LPC, LCSW, or licensed psychologist reviews MH/SUD inpatient admissions, while RNs review M/S inpatient admissions. Purpose of PA / CR / RR for both MH/SUD and M/S is to ensure medical necessity is met, detect and manage over- and under-utilization, assist with discharge planning and care management, identify quality improvement opportunities. RR occurs when the initial request for clinical review occurs after member is discharged (e.g., weekend or holiday admissions).

Per 13 CSR 70-3.180 Medical Pre-Certification Providers are required to seek pre-certification for certain specified services listed in the provider manuals, provider bulletins, or clinical edits criteria before delivery of the services. For both MH/SUD and M/S UHC analyzes data relevant to the reasons for assigning PA (e.g., high cost, over-utilization) to determine what services are assigned PA. The prior authorization list is to help drive more cost-effective quality health care for our members through reduction of services that fall outside of evidence-based guidelines ensuring that member receives clinically appropriate services at the right time in the right setting. The prior authorization list is reviewed on an annual basis to determine where the management of the benefits can be removed and added to the prior authorization list.

UHC uses LOCUS-CALOCUS for MH/SUD per State contract; however, inpatient preservice review is based on Treatment Milestone Assessment that is an algorithm that uses a combination of age, diagnosis, and history of prior admission to determine an authorization for initial length of stay. If the member does not have a prior admission history, then an administrative authorization based on proprietary

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evidence-based clinical guidelines will determine the authorization for the initial length of stay. MCG used for M/S admissions. For both MH/SUD and M/S if, through appeal, the provider establishes proof of authorization or mitigating circumstances, the claim is then reviewed for medical necessity and paid in full.

The health plan uses LOCUS-CALOCUS guidelines and Optum Policy and Coverage Decision documents for MH/SUD PA, CR, and RR requests for IP services and uses MCG Care guidelines and medical policy for M/S PA, CR, and RR requests.

Transplant services are provided to health plan members through FFS. The transplant prior authorization process requires the transplant facility or transplant surgeon to submit documentation that verifies the transplant candidate has been evaluated according to the facility’s Patient Selection Protocol and Patient Selection Criteria for the type of transplant to be performed. The patient must have been accepted as a transplant candidate by the facility before prior authorization requests can be considered for approval by the MO HealthNet Division. Physician reviews request and if not approved by first reviewer, it is sent to second physician reviewer.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Prior Authorization (PA) / Concurrent Review (CR) / Retrospective Review (RR) Health Plan/State: UnitedHealthcare, FFS Benefit Package(s): Category of Aid (COA) 4 (Ages 0-20), including ME 38 (ages 21-25), and foster children in and out of Jackson County Classification: Inpatient MH/SUD Benefits/Providers M/S Benefits/Providers UHC: N/A FFS: MH IP, MH SUD UHC: M/S IP FFS: Transplant Compliance Analysis For M/S, UHC does not require PA for inpatient admissions that are direct/emergent, per state contract. M/S scheduled inpatient admissions require prior authorization. When a member presents in an emergency room or for admission assessment, a pre-service authorization may be obtained within 24 hours of the receipt of the request. A request may be made via phone with clinical information. An RN will make a determination within 24 hours of the receipt of the request. A peer to peer with the medical director occurs within 3 business days of the facility being notified of a denial of an inpatient level of care. Only an MD can make an adverse determination. The MD has two days to make a final determination. M/S requests are by phone, and, when available, clinical information can be provided via access to EMR; clinical information is required for PA. Authorization is provided within 24 hours of receipt of the request for M/S. Peer to peer occurs within 3 business days of facility being notified of denial of inpatient level of care for M/S. RNs review M/S inpatient admissions.

For MH/SUD (provided to health plan members through FFS), PA is not required for emergent admissions; certification review takes place after admission.MH/SUD PA and CR requests are by phone, fax, or online. MH/SUD RR requests are submitted by fax or mail. Conduent utilizes the Milliman Care Guidelines® screening criteria to establish a benchmark length of stay for all inpatient hospitalizations. Strategy: authorization is required for services that are high cost and/or have potential for overutilization. MH/SUD uses Milliman Care Guidelines (MCG). For MH/SUD, reviewers of PA, CR, and RR requests are LPNs and RNs. MH/SUD requires inter-rater reliability training of utilization management staff. For MH/SUD certifications meeting criteria, CONDUENT (FFS) expects to certify the admission at the time of the initial request when made via CyberAccess or telephone. MH/SUD Certifications meeting criteria when submitted by written or fax request will be made by the end of the next working day. For MH/SUD requests for PA and CR, if the first reviewer is unable to approve, the second reviewer is a psychiatrist. Members have the right to appeal to Conduent for fee-for-service benefits and the right to a state fair hearing if the denial is upheld by Conduent.. Providers can appeal to the health plan for health plan covered services and to Conduent for fee-for-service covered benefits and to the administrative hearings commission in the event of disagreement with the initial appeal response.

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Per 13 CSR 70-3.180 Medical Pre-Certification Providers are required to seek pre-certification for certain specified services listed in the provider manuals, provider bulletins, or clinical edits criteria before delivery of the services. For M/S UHC analyzes data relevant to the reasons for assigning PA (e.g., high cost, over-utilization) to determine what services are assigned PA. The prior authorization list is to help drive more cost-effective quality health care for our members through reduction of services that fall outside of evidence-based guidelines ensuring that member receives clinically appropriate services at the right time in the right setting. The prior authorization list is reviewed on an annual basis to determine where the management of the benefits can be removed and added to the prior authorization list.

Transplant is carved out. The transplant prior authorization process requires the transplant facility or transplant surgeon to submit documentation that verifies the transplant candidate has been evaluated according to the facility’s Patient Selection Protocol and Patient Selection Criteria for the type of transplant to be performed. The patient must have been accepted as a transplant candidate by the facility before prior authorization requests can be considered for approval by the MO HealthNet Division.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Prior Authorization (PA), Concurrent Review (CR), Retrospective Review (RR) Health Plan/State: UnitedHealthcare / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate Classification: Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers United Healthcare: ECT, Psychiatric review of records, psychological testing if 5 hours or more FFS: CSTAR United Healthcare: Durable Medical Equipment and prosthetics, Home health, Private duty nursing, Cosmetic surgeries, Potential non- covered Medicaid services, Outpatient Chemotherapy, Outpatient Radiology, Surgical procedures FFS: ABA services Compliance Analysis UHC: Request by phone or EMR for MH/SUD and M/S. For MH/SUD and M/S services, requests must include clinical information, and are reviewed by licensed clinicians. Evidence: authorization required for services that are high cost and/or have the potential for overutilization . PA list is reviewed annually to determine needed changes and the purpose is to help drive more cost-effective quality health care for members through reduction of services that fall outside of evidence-based guidelines. LOCUS/CALOCUS used for MH/SUD (but not relevant for above services); MCG criteria are used for M/S services. Licensed healthcare professionals complete the initial review of PA requests for both MH/SUD and M/S. Timeliness of decision: 24 hours urgent, 36 hours routine for both MH/SUD and M/S requests. For both MH/SUD and M/S services, if denied: peer to peer is offered, adverse determinations are by physician only, and members have appeal rights.

CSTAR – Authorization required when exceed dollar package limits for SUD services and exceed 60 days of adolescent treatment support program. PA is requested through DMH CIMOR system. Licensed or credentialed staff review PA requests. Clinical rationale for additional dollars for continuation of intensive services is required. Evidence: history of individuals exceeding package dollar limits. Practice guidelines include ASAM components. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Timeliness of decision: 36 hours to include one working day. If denied: participant and provider have appeal rights within 30 days.

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FFS M/S: All ABA services require PA. Requests are submitted by fax or by mail. Clinical documentation of medical necessity is required. Requests are reviewed by licensed behavior analyst. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Evidence: Missouri best practice guidelines and BACB best practice guidelines. Abortion services are limited by medical necessity in accordance with the Hyde Amendment. Requests are by fax or mail and are reviewed by RN and physician. HCBS waiver services require PA.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Prior Authorization (PA), Concurrent Review (CR), Retrospective Review (RR) Health Plan/State: UnitedHealthcare / Missouri FFS / DMH Benefit Package(s): COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers UnitedHealthcare : N/A – provided through FFS for this population FFS: outpatient psychotherapy, psychological testing if under age 3, CSTAR

UnitedHealthcare: Durable Medical Equipment and prosthetics, Home health, Private duty nursing, Cosmetic surgeries, Potential non- covered Medicaid services, Outpatient Chemotherapy, Outpatient Radiology, Surgical procedures FFS: HCBS waiver services, ABA, abortion

Compliance Analysis FFS MH/SUD (provided through FFS for this population) – PA required beyond 4 hours in a rolling year for family, group, or individual therapy and for psychological testing if under age 3. CR does not apply. RR applies only in the event of retroactive eligibility. PA is requested by phone, fax, mail, or online. Clinical staff authorize PAs. PA form requires diagnosis, demographics, service requested, and attestation regarding training in EBP if applicable, that services are developmentally appropriate if under 5, that patient/guardian has agreed to treatment plan, whether court ordered, communication with other providers, treatment plan provided to CD case manager if applicable, if result of an EPSDT screen. Evidence: history of overutilization and cost overruns. Strategy: authorization required for services that are high cost and/or have the potential for overutilization . Timeliness of decision: Decisions typically made same day; online decisions are immediate. If denied: participant has appeal rights within 90 days; provider has appeal rights within 30 days

CSTAR – Authorization required when dollar package limits for SUD services are exceeded and when adolescent treatment support exceeds 60 days. PA is requested through DMH CIMOR system and reviewed by licensed or credentialed staff. CR requests can be submitted by phone, fax, email, or mail. Clinical rationale for additional dollars for continuation of intensive services is required. The DBH also offers a specialized CSTAR Program solely to participants between the ages of 12 and 17 years inclusive (exceptions to age criteria may be authorized through the Clinical Utilization Review process) and their families.

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Exceptions to these age requirements may be authorized through clinical utilization review documenting behavior and experience appropriate for the services available. Evidence: practice guidelines include ASAM components. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. Review completed within 36 hours to include one working day. To the extent feasible, a review request from a provider shall be made prior to delivery of services. If denied: appeal must be in writing, identify the reason for the appeal, and be received or postmarked within thirty (30) days of receiving notice that service authorization has been discontinued.

UHC M/S: Requests are submitted online, by phone, or fax. Requests include specified clinical information. Licensed healthcare professionals complete the initial review of PA requests. Timeliness of decision: 24 hours urgent, 36 hours routine. If denied: peer to peer is offered; adverse determinations by physician only; member has appeal rights. Evidence: to ensure clinical appropriateness and reduce overutilization. Strategy: authorization required for services that are high cost and/or have the potential for overutilization. FFS M/S: All ABA services require PA. Requests are submitted by fax or by mail. Clinical documentation of medical necessity is required. Requests are reviewed by licensed behavior analyst. Strategy is to prevent overutilization and ensure medical necessity of these time-intensive services. Evidence: Missouri best practice guidelines and BACB best practice guidelines. Abortion services are limited by medical necessity in accordance with the Hyde Amendment. Requests are by fax or mail and are reviewed retrospectively by RN and physician. HCBS waiver services require PA.

State Compliance Determination Complies Follow up Doesn’t Comply Action: State is reforming FFS policies to allow more services prior to authorization requirements.

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NQTL: Outlier Review Health Plan/State: UnitedHealthcare Benefit Package(s): Adults (21+), Pregnant Women (21+), Children: COA 1 (0-20), PW (0-20), CHIP Exp. (0-18), and CHIP Separate (0- 18), Classification: Emergency MH/SUD Benefits/Providers M/S Benefits/Providers UHC: Emergency FFS: N/A UHC: Emergency FFS: N/A Compliance Analysis MH/SUD and M/S: Outlier review is used to identify facilities with utilization or costs that may be outside the expected normal for their services. Internal Quality of Care, use of diagnostic services and admission rates, are standardly used to identify outlier facilities. Claims coding data is standardly used to address ED physician care. Fraud, Waste, Abuse, and Error (FWAE) Outlier reviews are conducted for FWA activities. Outlier review may also be used to identify facilities or providers who may need education on standard medical practices or assistance in improving their internal systems of care. United uses many national health care initiatives to address outlier identification such as the Accountable Care Act, the Centers for Medicare and Medicaid Services (CMS) programs and the National Priority Partnership (NPP) goals - CMS Hospital Compare web site for reporting - CMS Quality Strategy - NPP goals of decreasing: Hospital mortality rates; and - Potentially preventable ER visits In addition, national standard code sets for non-emergency emergency room utilization are used to identify possible excess ED usage and physician coding errors State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Outlier Review Health Plan/State: UnitedHealthcare Benefit Package(s): Adults (21+), Pregnant Women (21+), Children: COA 1 (0-20), PW (0-20), CHIP Exp. (0-18), and CHIP Separate (0- 18), Classification: Outpatient

MH/SUD Benefits/Providers M/S Benefits/Providers UHC: All outpatient services FFS: N/A

UHC: All outpatient services FFS: N/A

Compliance Analysis

MH/SUD and M/S: Internal Quality of Care and HEDIS quality measures are standardly used to assess for over- and under-utilization by providers. The Quality team, independently licensed RN’s, reviews HEDIS measures monthly.

Provider education and outreach is performed for providers who are assessed as experiencing over- or under-utilization by the quality team. Fraud, Waste, Abuse, and Error (FWAE) Outlier reviews are conducted for FWA activities. Outlier review may also be used to identify facilities or providers who may need education on standard medical practices or assistance in improving their internal systems of care. United uses many national health care initiatives to address outlier identification such as the Accountable Care Act, the Centers for Medicare and Medicaid Services (CMS) programs and the National Priority Partnership (NPP) goals

- CMS Hospital Compare web site for reporting - CMS Hospital Readmissions Reduction Program - CMS Hospital-acquired conditions payment adjustment - CMS Quality Strategy - NPP goals of decreasing: Hospital mortality rates; and - Potentially preventable ER visits and short-stay admissions and - Preventable hospital readmissions.

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In addition, United Healthcare has developed a proprietary methodology that uses LOCUS-CALOCUS Guidelines adjusted with its extensive data warehouse to develop normative values for hospital length of stay State Compliance Determination Complies Follow up Doesn’t Comply Action: ☒ ☐ ☐ NQTL: Outlier Review Health Plan/State: UnitedHealthcare Benefit Package(s): Adults (21+), Pregnant Women (21+), Children: COA 1 (0-20), PW (0-20), CHIP Exp. (0-18), and CHIP Separate (0- 18), Classification: Inpatient

MH/SUD Benefits/Providers M/S Benefits/Providers

Inpatient Admissions.

Inpatient Admissions.

Compliance Analysis

MH/SUD and M/S: Internal Quality of Care and HEDIS quality measures are standardly used to assess for over- and under-utilization by providers.

The Quality team, independently licensed RN’s, reviews HEDIS measures monthly. Provider education and outreach is performed for providers who are assessed as experiencing over- or under-utilization by the quality team. Fraud, Waste, Abuse, and Error (FWAE) Outlier reviews are conducted for FWA activities. Outlier review may also be used to identify facilities or providers who may need education on standard medical practices or assistance in improving their internal systems of care. United uses many national health care initiatives to address outlier identification such as the Accountable Care Act, the Centers for Medicare and Medicaid Services (CMS) programs and the National Priority Partnership (NPP) goals

- CMS Hospital Compare web site for reporting - CMS Hospital Readmissions Reduction Program - CMS Hospital-acquired conditions payment adjustment - CMS Quality Strategy - NPP goals of decreasing: Hospital mortality rates; and

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- Potentially preventable ER visits and short-stay admissions and - Preventable hospital readmissions. In addition, United Healthcare has developed a proprietary methodology that uses LOCUS-CALOCUS Guidelines adjusted with its extensive data warehouse to develop normative values for hospital length of stay. State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Outlier Review Health Plan/State: UnitedHealthcare Benefit Package(s): Category of Aid (COA) 4 (Ages 0-20), including ME 38 (ages 21-25), and foster children in and out of Jackson County Classification: Outpatient

MH/SUD Benefits/Providers M/S Benefits/Providers UHC: N/A FFS: N/A

UHC: All outpatient services FFS: N/A

Compliance Analysis

This NQTL is not used in FFS MH/SUD services.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Outlier Review Health Plan/State: UnitedHealthcare Benefit Package(s): Category of Aid (COA) 4 (Ages 0-20), including ME 38 (ages 21-25), and foster children in and out of Jackson County Classification: Inpatient

MH/SUD Benefits/Providers M/S Benefits/Providers UHC: N/A FFS: N/A

UHC: Inpatient Admissions.

Compliance Analysis

This NQTL is not used in FFS MH/SUD services.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

☒ ☐ ☐ NQTL: Documentation Requirements Health Plan/State: Home State / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Home State FFS for COA 4 / CSTAR Home State FFS: Transplant; ABA, HCBS Waiver, Abortion, IEP therapy services, private duty nursing and personal care IEP services, First steps services, audiology IEP services Compliance Analysis FFS behavioral health services regulation on documentation is more stringent than the MHD general regulation that applies to all providers. Specific elements are required for treatment plans, assessments, and progress notes. Reimbursement is recouped if audit finds documentation requirements are not met. Home State follows the same documentation requirements as the state.

CSTAR – Processes: When an individual presents for services and is determined eligible, the provider must complete the DLA-20© and enter the assessments results/scores in to CIMOR in order to bill.

Submission and Staffing: Provider completes the DLA-20© and enters the assessment scores into CIMOR. Staff conducting the DLA-20© must be trained by a trained trainer that received training from the developer. Approved bachelor's level staff or a qualified addiction professional (QAP) may administer the DLA-20©.

Strategy: The assessment helps to guide treatment, know where and what the individual needs assistance with. It is also to collect data for individuals served in the program as a measure of progress in treatment and CSTAR service efficacy. Tying the billing to the assessment helps ensure quality and needed services are being delivered to the individual. Outcomes measurement and monitoring helps individuals with substance use disorder manage their treatment which can reduce the need for specialized, high cost services.

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Timeline: DLA-20© documentation expected prior to billing per DBH policy, but no edit in system to prevent billing. Evidence: Published research supports use of this instrument.

State Compliance Determination Complies Follow up Doesn’t Comply Action: Amendment filed for 13 CSR 70-98.015. ☐ ☒ ☐

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NQTL: Documentation Requirements Health Plan/State: Missouri Care / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care FFS for COA 4 / CSTAR / Targeted Case Management

Missouri Care FFS: Transplant; ABA, HCBS Waiver, Abortion, IEP therapy services, private duty nursing and personal care IEP services, First steps services, audiology IEP services Compliance Analysis

FFS behavioral health services regulation on documentation is more stringent than the MHD general regulation that applies to all providers. Specific elements are required for treatment plans, assessments, and progress notes. Reimbursement is recouped if audit finds documentation requirements are not met. Missouri Care follows the same documentation requirements as the state.

CSTAR –

Processes: When an individual presents for services and is determined eligible, the provider must complete the DLA-20© and enter the assessments results/scores in to CIMOR in order to bill. Submission and Staffing: Provider completes the DLA-20© and enters the assessment scores into CIMOR. Staff conducting the DLA-20© must be trained by a trained trainer that received training from the developer. Approved bachelor's level staff or a qualified addiction professional (QAP) may administer the DLA-20©. Strategy: The assessment helps to guide treatment, know where and what the individual needs assistance with. It is also to collect data for individuals served in the program as a measure of progress in treatment and CSTAR service efficacy. Tying the billing to the assessment helps ensure quality and needed services are being delivered to the individual. Outcomes measurement and monitoring helps individuals with substance use disorder manage their

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treatment which can reduce the need for specialized, high cost services. Timeline: DLA-20© documentation expected prior to billing per DBH policy, but no edit in system to prevent billing. Evidence: Published research supports use of this instrument.

State Compliance Determination Complies Follow up Doesn’t Comply Action: Amendment filed for 13 CSR 70-98.015. ☐ ☒ ☐

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NQTL: Documentation Requirements Health Plan/State: UnitedHealthcare / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient

MH/SUD Benefits/Providers M/S Benefits/Providers UnitedHealthcare FFS for COA 4 / CSTAR / Targeted Case Management

UnitedHealthcare FFS: Transplant; ABA, HCBS Waiver, Abortion, IEP therapy services, private duty nursing and personal care IEP services, First steps services, audiology IEP services Compliance Analysis FFS behavioral health services regulation on documentation is more stringent than the MHD general regulation that applies to all providers. Specific elements are required for treatment plans, assessments, and progress notes. Reimbursement is recouped if audit finds documentation requirements are not met. UnitedHealthcare follows the same documentation requirements as the state.

CSTAR –

Processes: When an individual presents for services and is determined eligible, the provider must complete the DLA-20© and enter the assessments results/scores in to CIMOR in order to bill.

Submission and Staffing: Provider completes the DLA-20© and enters the assessment scores into CIMOR. Staff conducting the DLA-20© must be trained by a trained trainer that received training from the developer. Approved bachelor's level staff or a qualified addiction professional (QAP) may administer the DLA-20©.

Strategy: The assessment helps to guide treatment, know where and what the individual needs assistance with. It is also to collect data for individuals

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served in the program as a measure of progress in treatment and CSTAR service efficacy. Tying the billing to the assessment helps ensure quality and needed services are being delivered to the individual. Outcomes measurement and monitoring helps individuals with substance use disorder manage their treatment which can reduce the need for specialized, high cost services.

Timeline: DLA-20© documentation expected prior to billing per DBH policy, but no edit in system to prevent billing.

Evidence: Published research supports use of this instrument.

State Compliance Determination Complies Follow up Doesn’t Comply Action: Amendment filed for 13 CSR 70-98.015. ☐ ☒ ☐

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NQTL: Development, Modification, Addition of Medical Necessity/Medical Appropriateness/Level of Care Guidelines Health Plan/State: Home State Health / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Home State Health – Inpatient: Mental Health Hospital Inpatient, Residential Treatment FFS ACT, CMHC Healthcare Home, Youth TCM, Adult TCM Home State Health - Inpatient: Hospice, Hospital Services, Maternity Services, Nursing Home Care, Transplant Services, Skilled Nursing Facility, Surgical Services, Physician Services FFS: Transplant; ABA, HCBS Waiver, Abortion, IEP therapy services, private duty nursing and personal care IEP services, First steps services, audiology IEP services Compliance Analysis HSH – MH/SUD: Centene clinical policies developed through corporate clinical policy team. These policies emphasize clinical guidelines rather than service limitations. Begin with data analysis and research which is presented as a business case to their payment policy approval committee. Upon approval by committee, policy is developed and sent to clinical policy committee for edits. Policy is then sent to Centene plan president, CMOS, chief compliance officers, vice presidents of medical management, and vice presidents of networking for feedback. Policy is finalized after feedback from that group. Presented to individual plan committee for approval. Goes out 60 days prior to implementation. If MO HealthNet policy changes, it is sent to medical director for approval.

HSH – M/S and MH/SUD review annually. McKesson Interqual guidelines and MHD policy manuals and Centene clinical policies are utilized for M/S. LOCUS/CALOCUS are utilized for MH/SUD. Process for establishing clinical policies is same for MH/SUD and M/S.

DMH – ACT - Admission Criteria were developed based on research related to the evidence-based practice and consultation with national experts. Once criteria was developed by DBH, stakeholders were provided the opportunity to comment and provide feedback on

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the proposed eligibility criteria. Discussions resulted in the current eligibility requirements. This eligibility applies to individuals over the age 16. TCM - This service was based on federal guidelines, with consultation of stakeholders. Individuals must have an emergent or urgent situation and meet the criteria per current DSM.

CMHC Healthcare Home - Admission Criteria were developed based on research related and consultation with national experts. Criteria was developed by DBH along with stakeholders, including the Coalition of Behavioral Health Centers and providers. Discussions around the development of health care home was the initiated as a result of the Affordable Care Act. State Plan was submitted and approved by CMS for the Health Care Home service.

FFS: M/S services – medical necessity / level of care criteria based on peer-reviewed evidence base and national/state best practice guidelines. MH/SUD services - (provided to COA 4 managed care members through FFS) updated and reviewed annually with Milliman Care Guidelines (MCG) update. State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Development, Modification, Addition of Medical Necessity/Medical Appropriateness/Level of Care Guidelines Health Plan/State: Missouri Care / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care – Inpatient: Mental Health Hospital Inpatient, Residential Treatment FFS ACT, CMHC Healthcare Home, Youth TCM, Adult TCM Missouri Care - Inpatient: Hospice, Hospital Services, Maternity Services, Nursing Home Care, Transplant Services, Skilled Nursing Facility, Surgical Services, Physician Services FFS: Transplant; ABA, HCBS Waiver, Abortion, IEP therapy services, private duty nursing and personal care IEP services, First steps services, audiology IEP services Compliance Analysis WellCare’s Clinical Coverage Guidelines (CCG) for both M/S and MH/SUD are evidence based documents detailing the medical necessity of given procedure or technologies for the purposes of making coverage decisions under WellCare administered health benefit plans. Development of a new CCG is prompted if criteria currently being used does not include criteria for the requested service and/or the contractual requirements. Wellcare’s current CCGs are reviewed and updated annually. WellCare’s CCGs are based on evidence in the peer-reviewed published medical literature, technology assessments and structure evidence reviews, evidence-based consensus statements, expert opinions of health care practitioner/providers, and evidence-based guidelines from nationally recognized professional healthcare organizations and government public health agencies. InterQual criteria are used for M/S services, and LOCUS/CALOCUS for MH/SUD services.

DMH – ACT - Admission Criteria were developed based on research related to the evidence-based practice and consultation with national experts. Once criteria was developed by DBH, stakeholders were provided the opportunity to comment and provide feedback on the proposed eligibility criteria. Discussions resulted in the current eligibility requirements. This eligibility applies to individuals over the age 16. TCM - This service was based on federal guidelines, with consultation of stakeholders. Individuals must have an emergent or

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urgent situation and meet the criteria per current DSM.

CMHC Healthcare Home - Admission Criteria were developed based on research related and consultation with national experts. Criteria was developed by DBH along with stakeholders, including the Coalition of Behavioral Health Centers and providers. Discussions around the development of health care home was the initiated as a result of the Affordable Care Act. State Plan was submitted and approved by CMS for the Health Care Home service.

FFS M/S services – medical necessity / level of care criteria based on peer-reviewed evidence base and national/state best practice guidelines. MH/SUD services - (provided to COA 4 managed care members through FFS) updated and reviewed annually with Milliman Care Guidelines (MCG) update. State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Development, Modification, Addition of Medical Necessity/Medical Appropriateness/Level of Care Guidelines Health Plan/State: UnitedHealthcare / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers UnitedHealthcare – Inpatient: Mental Health Hospital Inpatient, Residential Treatment, outpatient MH/SUD services FFS ACT, CMHC Healthcare Home, Youth TCM, Adult TCM UnitedHealthcare – Inpatient and Outpatient M/S services FFS: Transplant; ABA, HCBS Waiver, Abortion, IEP therapy services, private duty nursing and personal care IEP services, First steps services, audiology IEP services Compliance Analysis For both MH/SUD and M/S services, the health plan/subcontractor develops and maintains clinical policies that describe the Generally Accepted Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding specific services. Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes.

The health plan may consult with professional clinical consultants, peer review committees, or other appropriate sources for recommendations regarding whether particular services, supplies or accommodations provided or to be provided to a Member are/were medically necessary. If no credible scientific evidence is available, then standards that are based on Physician specialty society recommendations or professional standards of care may be considered. The decision to apply Physician specialty society recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be within our sole discretion. Guidelines are reviewed and updated annually for both M/S and MH/SUD services.

For both MH/SUD and M/S services, unproven services are services, including medications, which are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-

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reviewed medical literature.

DMH – ACT - Admission Criteria were developed based on research related to the evidence-based practice and consultation with national experts. Once criteria was developed by DBH, stakeholders were provided the opportunity to comment and provide feedback on the proposed eligibility criteria. Discussions resulted in the current eligibility requirements. This eligibility applies to individuals over the age 16. TCM - This service was based on federal guidelines, with consultation of stakeholders. Individuals must have an emergent or urgent situation and meet the criteria per current DSM.

CMHC Healthcare Home - Admission Criteria were developed based on research related and consultation with national experts. Criteria was developed by DBH along with stakeholders, including the Coalition of Behavioral Health Centers and providers. Discussions around the development of health care home was the initiated as a result of the Affordable Care Act. State Plan was submitted and approved by CMS for the Health Care Home service.

FFS M/S services – medical necessity / level of care criteria based on peer-reviewed evidence base and national/state best practice guidelines. MH/SUD services - (provided to COA 4 managed care members through FFS) updated and reviewed annually with Milliman Care Guidelines (MCG) update. State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Network Admission Requirements: Provider Enrollment and Credentialing Health Plan/State: Home State Health / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Home State Health – Inpatient and Outpatient: Applicable to all provider and practitioner types under consideration for network participation.

FFS (outpatient): CPR, CSTAR, Adult TCM, & Youth TCM, clinic option providers (for COA 4); Inpatient (COA 4 if behavioral health admission only)

Home State Health – Inpatient and Outpatient: Applicable to all provider and practitioner types under consideration for network participation.

FFS: Inpatient and Outpatient: Applicable to all provider and practitioner types during enrollment.

Compliance Analysis Home State: Average length of time for MO initial credentialing is 12 days from Clean File determination to Credentials Committee Date (Q2 2017 data). Recredentialing applications are processed in accordance with NCQA requirements with all recredentialing occurring within 36 months. At the end of 36 months, if a provider has not recredentialed, they are terminated from our Network. However, if, in their 37th month, they provide their recredentialing documentation and are approved by Credentials Committee, per NCQA standards, we are able to reinstate the provider. For a practitioner or organizational provider (“provider”, collectively) to be considered for network admission, the provider must complete our application process online and submit all credentialing information, valid business documents, and licensing information. The provider is then sent a network participation agreement requesting signature. The provider's application for network participation is accepted and network participation agreement executed upon successful completion of our credentialing process in accordance with NCQA Standards and Guidelines, regulatory requirements, and managed care contractual obligations. Our provider network is continually enhanced and maintained in order to meet or exceed network adequacy requirements.• All providers within MO are credentialed the same. As we do not distinguish between provider types/specialties during credentialing. Home State Health Plan will accept and utilize the CAQH Universal Credentialing Data Source Form (UCDS), pursuant to RSMo 354.442.1 (15) and 20 CSR 400.7.180 (as amended), as the credentialing application for all practitioner credentialing in compliance with section 2.18.8c of the contract. Home State Health Plan requires verification of Bureau of Narcotics and Dangerous Drugs

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issued by the Missouri Department of Health & Human Services, if applicable. A current copy of the certificate is considered a valid source and meeting the requirement. Alternately, this may be verified online at: https://webapp01.dhss.mo.gov/mohworx/RegistrantSearch.aspx • As per Missouri 376.1578: The Company shall assess a health care practitioner's credentialing information and make a decision as to whether to approve or deny the practitioner's credentialing application within sixty (60) business days of the date of receipt of the completed application. A completed application is a practitioner's application to a health carrier that seeks the health carrier's authorization for the practitioner to provide patient care services as a member of the health carrier's network and does not omit any information which is clearly required by the application form and the accompanying instructions. The sixty-day (60) deadline established in this section shall not apply if the application or subsequent verification of information indicates that the practitioner has: a. A history of behavioral disorders or other impairments affecting the practitioner's ability to practice, including but not limited to substance abuse; b. Licensure disciplinary actions against the practitioner's license to practice imposed by any state or territory or foreign jurisdiction; c. Had the practitioner's hospital admitting or surgical privileges or other organizational credentials or authority to practice revoked, restricted, or suspended based on the practitioner's clinical performance; or d. A judgment or judicial award against the practitioner arising from a medical malpractice liability lawsuit. NP’s, PA’s, and provisionally licensed professionals are required to have a supervising physician form completed by an in-network physician. FFS – For MH/SUD and M/S, individual providers must submit copy of professional license and Medicare letter (if Medicare enrolled). For MH/SUD and M/S hospitals must be currently licensed by the Department of Health & Senior Services and Medicare certified as a hospital. Must submit a copy of the hospital license and Medicare certification letter.

DMH – Processes: (CPR, CSTAR & TCM) Provider agencies must be certified under both CPR and Core Rules state regulations in order to deliver and be reimbursed for CPR services by the Missouri Medicaid program, MO HealthNet. The DBH Division assures the agency has the ability and the qualified staff to deliver core services. The certification unit may make a site visit to determine if the agency meets certification standards, and/or require proof of other relevant accreditation status. If the provider is nationally accredited for behavioral health care from CARF International, The Joint Commission, or Council On Accreditation (COA) the department shall grant certification upon receipt of completed application and proof of national accreditation. Submission and Staffing: (CPR, CSTAR, & TCM) The steps for obtaining certification start with the provider agency completing a DBH certification application form and submitting that form to the DBH certification unit for review and approval. The form is submitted via mail, fax or electronically. The persons reviewing the DBH certification application form must meet the requirement as a Program Specialist and receive appropriate training which includes but is not limited to job shadowing, review of manuals, knowledge of standards, etc. Strategy: (CPR, CSTAR & TCM) To verify the provider agency applying for certification meet requirements in the Code of State Regulation that allows them to provide quality, effective services. Eligibility, safety, and quality care concerns are the primary factors in requiring that provider agencies seeking to provide services that meet certain minimal standards. Timeline: (CPR, CSTAR, & TCM) DBH certification unit has 30 days in which to determine whether the agency is eligible to be considered for certification.

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Additional time is required for site visit and determination if provider meets certification standards for agencies not nationally accredited. Failure to fully and accurately provide required information may increase certification time or result in non-certification. Provider certification is reviewed every three years. Evidence: (CPR, CSTAR, & TCM) State statute requires certification. The DBH Division, based on extensive experience in delivering quality behavioral health services, has determined that providers of CPR services should meet certain standards for staffing, administration, and service delivery that promote quality care for persons with serious mental illnesses. Practice guidelines support the rationale for this NQTL. TCM is supported by federal guidance. Appeal: (CPR, CSTAR, & TCM) Providers can appeal the decision if denied certification. If provider is denied certification or if their certification is revoked they may appeal to the Department Director. Then the provider's appeal is reviewed and a decision is made on the appeal. Provider has 30 days from the date of the notification of denial or revocation of certification to appeal to the Director. Provider must provide written notification/justification of appeal.

Processes: (CPR) This is a certification standard which: - When a provider agency hires a staff person to perform services or functions that require the individual staff meet staff requirements for applicable services. The agency assure persons used as QMHPs, Peer Supports in the CPR program meet one of the categories of staff specified in state regulations. This may include primary source verification of educational degree, license, or certification. -Requires CPR provider agencies have a process for granting and periodically reviewing clinical privileges to staff and establishes minimum elements for that process. When new staff are hired the agency must go through a process to grant clinical privileges for staff delivering services; and clinical privileges must be reviewed and renewed at a minimum every two (2) years. This is a process carried out by provider agencies, and they may develop their own forms to guide and support this. Agencies may require additional approval to perform certain services in addition to certification.

Access Crisis Intervention Programs (CPR): This NQTL applies to both adults and children and youth. State regulation requires that providers meet minimum staffing requirements for their ACI system for both the 24 hour crisis hotline and the mobile crisis response. Staff are required to have certain qualifications and experience, and trained appropriately. When a person is hired to work in the ACI system, that triggers the provider agency must go through a process that insures the person meets certain qualifications and is trained appropriately. There is also a requirement for continuing education and training with minimum hours that must be completed annually and within a two (2) year period. The provider agency may develop forms to guide and document this process at their discretion.

Intensive CPR – Residential (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR. It limits provider agencies operating the Intensive CPR Residential service to only those who operate CPR programs, and are approved for the service by DMH. It also requires that the clients receiving this service are enrolled in the rehabilitation level of care. The trigger is when a provider agency wants to become a provider of these services, and when they want to start enrolling clients. When a provider agency wants to start providing this service they must notify DMH, DBH Division, and receive approval to deliver the service. Then when they enroll clients to be served, the provider must assure they are enrolled in the correct level of care. The team of staff that provide these services must be trained to provide the services and must be supervised by the QMHP.

Peer Support (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. It sets forth the staff qualifications and service definition for Certified Missouri Peer Specialists who deliver peer support services. When a provider agency wants to employ a person to provide peer support services, they must assure the person has at least a high school diploma or equivalent and has received the required training and passed the test in order to be a Certified Missouri Peer Specialist.

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Psychosocial Rehabilitation (CPR): When an agency develops a psychosocial rehabilitation (PSR) program they must have that program either accredited by CARF, or licensed as a day program by DMH under licensure regulations. This NQTL further directs that if certification standards are more restrictive than licensure standards, then certification standards should prevail. Further, it limits the person assigned as the director of the adult PSR program must be a qualified mental health professional. For the youth PSR program the director of the program must be a qualified mental health professional with at least two (2) years of relevant work experience. This is in the Missouri Medicaid Provider Manual for CPR and sets limitations on how many persons can be served in an adult PSR program in relation to staffing. Staff to client ratios may not exceed 1:16; program needs or client mix may require even lower staff to client ratios; and at least one (1) staff person must be present at all times at the program site. When provider agencies are planning staffing coverage for a PSR program, they need to assure they have adequate staffing to meet these requirements. These are requirements in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. One (1) full time equivalent mental health professional shall be available during the provision of services. The staffing ratios shall be based on the client’s age. For those clients between the ages of three (3) and 11, the staffing ratio shall be one (1) staff to four (4) clients. For those clients between the ages of 12 and 17, the staffing ratio shall be one (1) staff to six (6) clients. Other staff of the PSR team shall be composed of the following providers as needed by the children: 1. a registered nurse; 2. an occupational therapist; 3. a recreational therapist; 4. a rehabilitation therapist; 5. a community support specialist; or, 6. family assistance worker.

Individual and Group Counseling PSR (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. It sets forth the staff qualifications and training requirements for persons providing Individual and Group Professional PSR. It is required that whenever a provider agency hires a staff person to provide Individual and Group Professional PSR, they must assure the person hired meets one of the staffing qualifications and has received the required training in mental health services. Qualified staff must be a professional counselor licensed or provisionally licensed under Missouri law and with specialized training in mental health services; or, a clinical social worker licensed or master social worker licensed under Missouri law and with specialized training in mental health services; or, a psychologist licensed or provisionally licensed or temporary licensed under Missouri law with specialized training in mental health services. Staff providing individual and group professional psychosocial rehabilitation services must have additional initial training such as, cognitive behavioral therapy, creating a recovery based mental treatment plan, Illness management and recovery, motivational interviewing, and introduction to DBT.

PSR – IMR (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. This limits providers of the PSR-IMR service to only those who have been approved by the DBH Division. Providers must submit in writing to the division a plan to implement this service along with planned curriculum, in order to get approval. The trigger is when a provider agency decides to implement this service for the first time, or to add new curriculum to a PSR-IMR program already operating.

Co-Occurring Services (CPR): This is a requirement in the CPR state regulation, regarding qualified staff who work in Integrated Dual Disorders Treatment (IDDT) programs. This sets forth minimum requirements for a person to be considered a QMHP or Qualified Addiction Professional (QAP) and meet co-occurring counselor competency requirements established by DBH. When an agency hires a person for a QAP position in an IDDT program, they must assure they meet one of the two qualification types above. This is a requirement in the CPR state regulation regarding fidelity reviews and quality improvement plans in Integrated Dual Disorders Treatment (IDDT) programs. Agencies delivering these services are required to follow the SAMHSA evidence based guidelines for IDDT, are required to receive fidelity reviews from the DBH Division, and are required to have a quality improvement plan as specified above. The trigger is an agency starting to implement an IDDT program, and annually thereafter when fidelity reviews come due. DBH staff utilize a standardized tool and form in fidelity reviews. It is required that agencies receive a fidelity review initially and annually thereafter. In addition the provider agency must develop and maintain a quality improvement plan that

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meets certain requirements in the regulation. DBH Division staff who conduct fidelity reviews must be trained and knowledgeable in IDDT.

Co-Occurring Services - Individual Counseling, Group Counseling, Group Education, and Co-Occurring Assessment Supplement (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. This establishes who an eligible staff person is to provide Co-Occurring Individual Counseling, Co-Occurring Group Counseling, Co-Occurring Group Education and Co-Occurring Assessment Supplement in an IDDT program. When a provider agency hires a person to deliver Co-Occurring Individual Counseling, Co-Occurring Group Counseling, and Co-Occurring Assessment Supplement in an IDDT program, they must assure the person is either a QMHP or a Qualified Addiction Professional (QAP), and meet co- occurring counselor competency requirements established by DMH. When a provider agency hires a person to deliver Co-Occurring Group Education in an IDDT program, they must assure the person has documented education and experience related to the topic presented and either be or be supervised by a QMHP or a QAP who meets co-occurring counselor competency requirements established by DMH.

Assertive Community Treatment (CPR): This is in state regulation and establishes minimum staffing requirements for Assertive Community Treatment (ACT) teams. When a provider agency hires staff for their ACT teams they must assure those staff meet requirements as follows:  The team shall have adequate nursing capacity by meeting one (1) of the following: o A registered professional nurse with six (6) months of psychiatric nursing experience shall work with no more than fifty (50) individuals on a full- time basis during the first year of program operation o During the first year of program operation, a registered professional nurse shall work with no more than fifty (50) individuals as a seventy-five percent (75%) Full-Time Equivalent (FTE) for up to twelve (12) months;  A team leader who is a qualified mental health professional as defined in 9 CSR 30-4.030(2)(HH) that is full time with one (1) year of supervisory experience and a minimum of two (2) years of experience working with adults with serious mental illness in community settings;  The team shall have adequate substance abuse treatment capacity by meeting one (1) of the following: 1. A substance abuse specialist who is a qualified substance abuse professional (QSAP) as defined in 9 CSR 10-7.140(2)(RR)1. or 2. with one (1) year of training or supervised experience in substance abuse treatment shall be assigned to no more than fifty (50) individuals; or 2. If the QSAP is not assigned to a team full time or is assigned to a team with less than fifty (50) individuals, the QSAP shall attend at least two (2) team meetings per week; or 3. A QSAP who has less than one (1) year experience in Integrated Dual Disorders Treatment (IDDT) shall be actively acquiring twenty-four (24) hours of training in IDDT- specific content and receive supervision from experienced IDDT staff;  The team shall have adequate vocational specialization capacity by meeting one (1) of the following: o A vocational specialist who qualifies as a community support worker as defined in 9 CSR 30-4.034(2)(H)1. with one (1) year of experience and training in vocational rehabilitation and supported employment shall be available to no more than fifty (50) individuals; or o If the vocational specialist is not assigned to a team full time or is assigned to a team with less than fifty (50) individuals, the vocational specialist shall attend at least two (2) team meetings per week; or o A vocational specialist with six (6) months of vocational experience shall work with no more than fifty (50) individuals on a full-time basis during the first year of program operation;  The team shall include a peer specialist which shall be self-identified as a present or former primary consumer of mental health services; be assigned full time to a team and shall participate in the clinical responsibilities and functions of the team in providing direct services; and serve as a model, a support, and a resource for the team members and individuals being served by the first year of program operation. Peer specialists, at a minimum, shall meet the qualifications of a community support assistant as defined in 9 CSR 30-4.030(2)(P) and 9 CSR 30-4.034(2)(H)2.;  The team shall include a program assistant. A team of one hundred (100) individuals requires one (1) Full Time Equivalent (FTE) prorated based on

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team size. The program assistant shall have education and experience in human services or office management. The program assistant shall organize, coordinate, and monitor all non-clinical operations of the team including but not limited to the following: o Managing medical records; o Operating and coordinating the management information system; and o Triaging telephone calls and coordinating communication between the team and individuals receiving ACT services;  Other team members may be assigned to work exclusively with the team and must qualify as a community support worker or a qualified mental health professional as defined in 9 CSR 30-4.034 (2)(H)1. or 9 CSR 30-4.030(2)(HH); and  In addition to training required in 9 CSR 30-4.034, team members shall receive ongoing training relevant to ACT services.

Contract (CPR & TCM): This NQTL applies to both adults and children and youth. These requirements are in the Administrative Agent Master Contract agreement. Administrative Agents are required to operate CPR programs for adults and children and youth, and TCM programs for adults and children and youth.  Further, this NQTL requires that they employ one or more full time Community Mental Health Liaisons (CMHLs), and sets forth minimum qualifications and training requirements for a CMHL. These liaison positions shall be filled by experienced, qualified mental health professionals who are: (a) Trained in assessment and crisis intervention; (b) Knowledgeable about the local system of care including, but not limited to, the operation of the community providers, the Access Crisis Intervention (ACI) system, inpatient psychiatric resources, civil commitment procedures, and guardianship laws; and c. Knowledgeable about behavioral health disorders and co-occurring disorders.  Contractors are required to incorporate trauma informed approaches into service delivery. As the agency develops policies, procedures, and processes to assess and serve clients, they should be considering trauma informed approaches. It is required that administrative agents incorporate trauma informed approaches into service delivery that actively consider the likelihood of a consumers trauma experience.

(CSTAR) Initial certification request and/or renewal process for existing certification by a provider. In order for an agency to be a CSTAR provider they must submit an application to DBH requesting CSTAR certification; they must comply with applicable standards as stated in the rule in addition to program specific rules as stated in standards. Agency must then be approved by DMH as a CSTAR provider. This process needs to be done initially and then every three years, the provider will have to complete the DBH certification application. The organization must comply with the standards applicable to each program for which certification is being sought.

Staff vacancy, new service and/or service expansion triggers hiring of qualified professionals. Provider must be knowledgeable of staff qualifications for each service. The agencies must hire/train staff and supervise staff and ensure continuous eligibility for service provision. Qualified staff must be available before services can be delivered. The person responsible for ensuring qualified staff for a given service must be knowledgeable of the service requirements.

Provider must obtain primary source verification to determine potential staff's status to determine:  If the person is eligible to provide the service now or if the person is a student and not currently eligible through prior experience and/or education.  If the person meets the requirements of an: o Qualified Substance Abuse Professional  A physician or qualified mental health professional meeting the educational/experiential/supervision requirements for licensure as

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established by the Missouri Division of Professional Registration who has at least one year of full-time experience in the treatment or rehabilitation of persons with substance use disorders; or  A person meeting the educational/experiential/supervision requirements for certification or registration as a substance abuse professional by the Missouri Substance Abuse Professional Credentialing Board. o Associate Counselor  The associate counselor is a trainee that must meet requirements set forth by the Missouri Credentialing Board or the appropriate board of professional registration within the Department of Economic Development. o Licensed Mental Health Professional  Provisional licensure as a mental health professional will satisfy the licensure requirement for designation as a QAP, including the qualifications required to deliver trauma-related and co-occurring disorders-related services. However, all other requirements related to provider qualifications must be met and demonstrated. o Community Support Specialist  Must meet one of the following qualifications:  A mental health professional as defined in 9 CSR 10 – 7.140 (2) (QQ);  An individual with a bachelor’s degree in a human services field, which includes social work, psychology, nursing, education, criminal justice, recreational therapy, human development and family studies, counseling, child development, gerontology, sociology, human services, behavioral science and rehabilitation counseling;  An individual with any four year degree and two years of qualifying experience;  An individual with any four year combination of higher education and qualifying experience, or o An individual with four years of qualifying experience.  Qualifying experience must include delivery of service to individuals with mental illness, substance use disorder or developmental disabilities. Experience must include some combination of the following:  Providing one-on-one or group services with a rehabilitation/habilitation and recovery/resiliency focus;  Teaching and modeling for individuals how to cope and manage psychiatric, developmental or substance use issues while encouraging the use of natural resources;  Supporting efforts to find and maintain employment for individuals and/or to function appropriately in families, school and communities;  Assisting individuals to achieve the goals and objectives on their person centered individualized treatment plans.  It is also required that the Community Support Specialist complete the necessary orientation and training requirements specified by DMH. o Co-Occurring Counselor  Co-occurring disorder individual counseling is provided by either a person licensed by the Missouri Division of Professional Registration as a mental health professional who is practicing within their current competence; or, a person certified by the Missouri Credentialing Board as a professional working in co-occurring disorders who is practicing within their current competence. o Trauma Counselor  Trauma individual counseling is provided by a licensed mental health professional who is a qualified addiction professional (QAP). Qualified staff must have specialized trauma training and/or equivalent work experience and shall utilize an evidence-based treatment model for the delivery of this service.; or  Has the ability/training/etc. to provide:

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o Any CSTAR Service  Intake Assessment – Qualified Addiction Professional (reviews and interprets assessment data and meets with consumer to develop treatment recommendations), and licensed diagnostician (renders a five-axis diagnosis). Other components included in service description:  Outcome Measurement – Community Support Worker or Qualified Addiction Professional; and  Assessment and Diagnostic Update – Qualified Addiction Professional (reviews and interprets assessment data and meets with consumer to develop treatment recommendations), and licensed diagnostician (renders a five-axis diagnosis)  Community Support – Community Support Worker  Individual Counseling – Qualified Addiction Professional or Associate Counselor. Evidence based interventions requires Licensed Mental Health Professional that is a Qualified Addiction Professional with relevant training/experience or specific credentials.  Group Counseling – Qualified Addiction Professional or Associate Counselor  Group Therapeutic Substance Abuse Education – Individual with appropriate background, experience and knowledge and demonstrated competencies and skills  Day Treatment – Activities and interventions delivered under supervision of Qualified Addiction Professional  Family Therapy – Licensed or certified marriage and family therapist, or qualified professional as defined in 9 CSR 30-3.110(6)(D)  Codependency Counseling – Family Therapist or Qualified Addiction Professional with appropriate training  Detoxification Services – A team that includes a licensed physician or Advanced Practice Nurse, registered and licensed nursing staff and other specialty trained staff  Medication Services – Licensed Physician or Advanced Practice Nurse  Extended Day Treatment – Licensed, Registered Nurse o Group Therapeutic Substance Use Disorder Education  Group therapeutic substance use disorder education services shall be provided by an individual who:  Is suited by education, background or experience to teach the information being presented;  Demonstrates competency and skill in educational techniques;  Has knowledge of the topic(s) being taught; and,  Is present with participants throughout the group therapeutic substance use disorder education session.  In addition, staff who provide information about human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) shall have completed a department approved or comparable training program. o Trauma Group Education  Trauma group education must be provided by staff with specialized training in trauma and addiction. o Family Therapy  Unless otherwise approved and documented by DMH, family therapy shall be performed by a person who:  Is licensed in Missouri as a marital and family therapist; or  Is certified by the American Association of Marriage and Family Therapists; or  Has a graduate (doctoral or masters) degree in psychology, social work or counseling and has at least one year of supervised experience in family counseling and has specialized training in family counseling; or has a graduate (doctoral or masters) degree in psychology, social work or counseling and receives close supervision from an individual who meets the above requirements; or,  A degreed, qualified addiction professional who receives close supervision from an individual that meets the above

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requirements. o Collateral Dependent Counseling  Assessments, individual counseling and group counseling services provided to children under age 12 shall be provided by:  A social worker, counselor, psychologist or physician licensed in Missouri who has at least one year of full-time experience in the assessment and treatment of children; or,  A graduate of an accredited college or university with a master’s degree in social work, psychology, counseling, psychiatric nursing or closely related field, which has at least two years of full-time equivalent experience in the treatment and assessment of children. Group collateral dependent services for therapeutic substance use disorder education for children under age 12 shall be provided by a graduate of an accredited college or university with a bachelor's degree in counseling, psychology, social work or closely related field. o Individual and Group Counseling  A majority of the program’s staff who provide individual and group counseling shall be qualified substance abuse professionals. o Extended Day Treatment  This service consists of medical and other consultative services provided by a registered nurse for the purposes of monitoring and managing a participant’s health, and medication management.  A registered nurse (RN) with relevant education, experience, and competency is available on site or by phone for 24-hour supervision. o Opioid Treatment Program  When a person works in an Opioid Treatment setting the provider must provide or arrange and document ongoing training that consists of at least 14 hours of training for all staff working in an Opioid Treatment setting every 2 years. The provider must include in their HR processes a method to ensure trainings are occurring, staff are attending and training is documented with at least 14 hours of training every 2 years. o Adolescent Treatment Support  Service delivery staff shall:  Have training and demonstrate expertise regarding the treatment of both substance use disorders and other disorders related to adolescents; and,  Receive clinical supervision by an appropriately licensed, certified, or otherwise credentialed person with experience in the treatment of adolescents.  Participants shall be supervised at all times by a staff member with current certification in first aid and cardiopulmonary resuscitation. o Communicable Disease Counseling  Prior to being tested for HIV, counseling must be provided by individuals who are knowledgeable about communicable diseases including HIV, TB and STDs through training and/or previous employment experience.  Staff’s knowledge shall include awareness of risks, disease management/treatment and resources for care, and confidentiality requirements when working with special populations. Post-test counseling may be provided for those testing positive for either HIV or TB. Staff providing these services shall also be competent to therapeutically assist consumers to understand and appropriately respond to test results. Post-test counseling for HIV or TB must also be knowledgeable about services and care coordination available through the DHSS.  Supervision

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o Credentials for Supervisor of Counselors. Unless otherwise required by these rules, supervision of counselors must be provided by a qualified substance abuse professional who has  A degree from an accredited college in an approved field of study; or  Four (4) or more year’s employment experience in the treatment and rehabilitation of persons with substance abuse problems. o Credentials for Supervisor of Community Support Workers. A community support worker shall be supervised by an individual with  A master’s degree from an accredited college or university in social work, counseling, psychology or a closely related field and at least one (1) year of full-time equivalent experience in providing community support services; or  A bachelor’s degree from an accredited college or university in social work, counseling, psychology or a closely related field and at least two (2) years of full-time equivalent experience in providing community support services; and  Demonstrated competencies in the areas of supervision and substance abuse treatment and rehabilitation by virtue of experience and/or training.

Other Applicable Program Requirements. A CSTAR program shall meet the following additional requirements, when the department determines that they are applicable:  Services offered on a residential basis shall comply with requirements for residential treatment; and  Requirements as a specialized program for adolescents or as a specialized program for women and children shall be met, where applicable.

All detoxification services shall be provided in a humane manner and shall ensure the safety and well-being of persons served.  There shall be monitoring and assessment of the person’s physical and emotional status during the detoxification process. o Vital signs shall be taken on a regular basis, with the frequency determined by client need based on a standardized assessment instrument. o Blood alcohol concentration may be monitored upon admission and thereafter as indicated. Further testing of urine or blood may be conducted by qualified personnel.  Staff coverage in residential settings shall ensure the continuous supervision and safety of clients. o Two (2) staff members shall be on-site at all times, and additional staff may be required, as warranted by the size of the program and the responsibilities and duties of staff members. o Staff providing direct supervision and monitoring of clients shall demonstrate competency in recognizing symptoms of intoxication, impairment and withdrawal; monitoring vital signs; and understanding basic principles and resources for substance abuse treatment. o Clients shall be supervised at all times by a staff member with current certification in first aid and cardiopulmonary resuscitation. When the Department notifies providers of newly required training, the provider would ensure staff received the required training and document training within the timeframe set by the Department. The providers must provide or arrange for their staff to receive specified training.

If a religious entity contracts with DMH, the religious organization must meet the same requirements as non-religious organizations per block grant as well as comply with federal requirement pertaining to charitable choice provisions and regulations. (TCM) A provider of TCM services is an entity that is designated by the DMH. Designation is contingent upon the provision of the core services listed below. These services may be provided directly or by subcontract. The required service functions include the following:  Assessment and periodic reassessment  Case Coordination

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 Case Monitoring  Case Documentation  Supported Community Living (SCL) Functions TCM services are provided by community mental health facilities approved to provide this service by the Department of Mental Health. Administrative Agent of DMH hire and employs Targeted Case Managers and QMHP for the purpose of administration of TCM. Administrative agent verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Individual must meet requirement prior to rendering services.  Targeted Case Managers o For youth, must at a minimum be a graduate from an accredited four (4) year college or university with a specialization in sociology, psychology, social work, or closely related fields and at least one (1) year of full-time equivalent experience in working with children and families. o For adults, must have graduated from an accredited four (4) year college or university with a specialization in sociology, psychology, social work, or closely related fields or a graduate from an accredited four (4) year college or university with related work experience. Relevant human service delivery experience can be substituted on a year for year basis for the four year degree.  A qualified mental health professional (QMHP) for the purpose of administration of the MO HealthNet TCM, is defined as: o A physician licensed under Missouri law to practice medicine or osteopathy and with training in mental health services or one year of experience, under supervision, in treating problems related to mental illness and serious emotional disturbances. o A psychiatrist licensed under Missouri law as a physician and who has successfully completed a training program in psychiatry approved by the American Medical Association, the American Osteopathic Association, or other training program identified as equivalent by DMH. o A psychologist licensed under Missouri law to practice psychology with specialized training in mental health services. o A professional counselor licensed under Missouri law to practice counseling with specialized training in mental health services. o A clinical social worker licensed under Chapter 337 RSMo. o A psychiatric nurse licensed under Chapter 335 RSMo., as a registered professional nurse with at least two years of experience in a psychiatric or substance use disorder treatment setting or a master’s degree in psychiatric nursing. o An individual possessing a master’s or doctorate degree in counseling and guidance, vocational counseling, pastoral counseling, rehabilitation counseling and guidance, psychology, family therapy, or related field, who has successfully completed a practicum or has one year of experience under the supervision of a qualified mental health professional. o An occupational therapist certified by the American Occupational Therapy Certification Board, registered in Missouri, who has a bachelor’s degree and has completed a practicum in a psychiatric setting or has one year experience in a psychiatric setting or has a master’s degree and has completed either a practicum in a psychiatric setting or has one year of experience in a psychiatric setting. o An advanced practice nurse under Chapter 335.016 RSMo who has had education beyond the basic nursing education and is certified by a nationally recognized professional organization as having a nursing specialty, or who meets criteria for advanced practice nurses established by the board of nursing. o A psychiatric pharmacist who is a registered pharmacist in good standing with the Missouri Board of Pharmacy who is a board certified pharmacist (BCPP) through the Board of Pharmaceutical Specialties or a registered pharmacist currently in a psycho-pharmacy residency where the service has been supervised by a board certified psychiatric pharmacist.

(HCH) Provider initially must complete an application form. Enrollment forms must be completed in order for an individual to be part of a HCH. The HCH

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provider must complete specified forms and submit to DBH, including monthly implementation report and monthly status report, monthly hospitalization follow-up report in addition they have to complete an attestation and send to MO HealthNet to support the services were provided and they have to submit data to a contracted population health platform. Agencies must meet staffing requirements for HCH Directors, Nurse Care Managers, care coordinators and Primary Care Physician Consultants per the staffing memo. HCH organizations must also meet national accreditation standards for HCHs. They must maintain CPR certification and contract with DBH and fulfill all requirements such as participation in scheduled trainings, meetings/phone conferences/webinars and submission of data as required. (HCH) In order to be a CMHC HCH, the provider must be certified as a CPR provider and hold a contract with DBH/DMH. They have to apply to DBH to be a HCH and be approved based on staffing patterns and expected practices. The DBH then recognizes the organization as an adult and or youth HCH.

Initial and renewal of recognition as CMHC HCH every 3 years.

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Submission and Staffing: (CPR) This requires that all personnel provided by contracted agencies have criminal background checks in accordance with state law. When a contracted provider agency hires a new staff person, it is required that staff at contracted agencies have background checks completed. Depending on the service there is also a requirement for continuing education, training with minimum hours that must be completed annually and within a two (2) year period and passing any applicable test. The provider agency may develop forms to guide and document this process at their discretion. Some services require a staff to client ratio. The provider must also complete a clinical privileges process for staff to assure they meet qualification and training requirements to provide those services. Clinical privileging process must be done initially and every 2 years for all staff providing CPR service.

(CSTAR) Provider verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Depending on the service there is also a requirement for continuing education, training with minimum hours that must be completed within a two (2) year period. Some services require a staff to client ratio.

(TCM) Administrative agent verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Individual must meet requirement prior to rendering services.

(HCH) Administrative agent verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Individual must meet requirement prior to rendering services. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Strategy: (CPR) The purpose is to assure: staff with service and management responsibility meet certain minimal standards; agencies have the staffing in place to provide quality services; and that persons providing behavioral health services have the qualifications and skills to provide services.

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Clinical efficacy and safety concerns are the primary factors.

(CSTAR) The purpose of this NQTL is to ensure staff are appropriately trained and qualified to provide services, stay abreast of and demonstrate competency regarding changes and evolving practices in the field. The state sets staff qualifications and competency requirements in order to ensure quality service provision for the delivery of culturally sensitive and evidenced based practices. Factors in determining the NQTL include safety, clinical efficacy, quality of care, and quality services. We want to ensure that the services being delivered are not doing more harm than good.

(TCM) The purpose of this NQTL is to ensure services are responsive to the individual's full range of needs and to assure services are provided by a qualified professional operating within their scope of practice. Clinical efficacy, elasticity of demand, licensing and accreditation were considered when determining the NQTL.

(HCH) The purpose of the HCH is to provide better care coordination and chronic disease monitoring of individuals with serious mental illness or severe emotional disturbance ultimately reducing costs and decreasing mortality. The purpose of the organization's required certification, accreditation and data reporting is to ensure quality outcome measures are met. Eligibility and coverage confirmation; safety concerns; cost of treatment; variability in cost and quality; clinical efficacy. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Evidence: (CPR) General best practices, SAMSHA, practice guideline, national standards, stakeholder involvement

(CSTAR) General best practices, SAMSHA, practice guideline, national standards, stakeholder involvement

(TCM) CMS guidance and SSA as follows: o CMS-2237-IFC(3) states "case management services are comprehensive and must include all of the following: assessment of an eligible individual (42 CFR 440.169(d)(1)); development of a specific care plan (42 CFR 440.169(d)(2)); referral to services (42 CFR 440.169(d)(3)); and monitoring activities (42 CFR 440.169(d)(4))." To allow for consistent monitoring, oversight and timely updates/revisions the criteria for the provider is reviewed every three years if provider is not accredited. If provider is accredited criteria is reviewed every 3 or 4 years depending on accreditation body standards. MO HealthNet TCM provider manual is reviewed and updated yearly. o Section 1905(a)(13) of the Social Security Act and 42 CFR §440.130(d) provide that States may cover rehabilitative services: “including any medical or remedial services (provided in a facility, a home, or other setting)recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level. CMS 2237 IFC requires states to specify provider qualifications. CMS guidance CMS-2237-IFC (7) states "When a target group consists solely of individuals with developmental disabilities or chronic mental illness, States my limit provider participation to specific persons or entities by setting forth qualifying criteria that assure the ability of the case managers to connect individuals with needed services". To allow for consistent monitoring of required staff qualifications, certification for the provider is reviewed every three years if provider is not accredited.

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If provider is accredited criteria is reviewed every 3 or 4 years depending on accrediting body standards. MO HealthNet TCM provider manual is reviewed and updated yearly.

(HCH) Published research-CATIE study that references that individuals with serious mental illness die 25 years younger than the general population due to preventable chronic diseases. DBH also utilizes population health data to determine target areas of treatment. DMH utilizes the data submitted to DBH from HCH providers to help providers focus their treatment. Criteria was developed by DBH along with stakeholders, including the Coalition of Behavioral Health Centers and providers. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Appeal: (All) DMH Exceptions Committee hears requests for waiver to a rule regarding staff qualifications for services.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Network Admission Requirements: Provider Enrollment and Credentialing Health Plan/State: Missouri Care / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care – Inpatient and Outpatient: Applicable to all provider and practitioner types under consideration for network participation.

FFS (outpatient): CPR, CSTAR, Adult TCM, & Youth TCM, clinic option providers (for COA 4); Inpatient (COA 4 if behavioral health admission only)

Missouri Care – Inpatient and Outpatient: Applicable to all provider and practitioner types under consideration for network participation.

FFS: Inpatient and Outpatient: Applicable to all provider and practitioner types during enrollment.

Compliance Analysis Missouri Care: WellCare provides contracted networks of qualified organizational health care providers, and home and community-based service providers (as applicable to state) to the enrolled membership in its Plan. WellCare performs initial and ongoing assessments of its organizational providers in compliance with applicable local, state, and federal accreditation requirements. Information and documentation on organizational providers is collected, verified, reviewed, and evaluated in order to achieve a decision to approve or deny network participation. Policy(ies): C7CR-009, C7CR- 001, C7CR-004, C7CR-009-PR-001. The State of Missouri requires that Missouri Care contract and credential multiple CMHC, FQHC, RHC, LPHA and other like Agencies. The requirements for credentialing are:  An Application  Proof of Accreditation / State or Health Plan Site visit  Proof of Federal or State Designation as a qualifying Agency

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 General Liability Missouri Care’s goal length of time for the credentialing and re-credentialing process for MH/SUD and for M/S providers is less than 60 days. Our current turnaround time is <35 days.

FFS – For MH/SUD and M/S, individual providers must submit copy of professional license and Medicare letter (if Medicare enrolled). For MH/SUD and M/S hospitals must be currently licensed by the Department of Health & Senior Services and Medicare certified as a hospital. Must submit a copy of the hospital license and Medicare certification letter.

DMH – Processes: (CPR, CSTAR & TCM) Provider agencies must be certified under both CPR and Core Rules state regulations in order to deliver and be reimbursed for CPR services by the Missouri Medicaid program, MO HealthNet. The DBH Division assures the agency has the ability and the qualified staff to deliver core services. The certification unit may make a site visit to determine if the agency meets certification standards, and/or require proof of other relevant accreditation status. If the provider is nationally accredited for behavioral health care from CARF International, The Joint Commission, or Council On Accreditation (COA) the department shall grant certification upon receipt of completed application and proof of national accreditation. Submission and Staffing: (CPR, CSTAR, & TCM) The steps for obtaining certification start with the provider agency completing a DBH certification application form and submitting that form to the DBH certification unit for review and approval. The form is submitted via mail, fax or electronically. The persons reviewing the DBH certification application form must meet the requirement as a Program Specialist and receive appropriate training which includes but is not limited to job shadowing, review of manuals, knowledge of standards, etc. Strategy: (CPR, CSTAR & TCM) To verify the provider agency applying for certification meet requirements in the Code of State Regulation that allows them to provide quality, effective services. Eligibility, safety, and quality care concerns are the primary factors in requiring that provider agencies seeking to provide services that meet certain minimal standards. Timeline: (CPR, CSTAR, & TCM) DBH certification unit has 30 days in which to determine whether the agency is eligible to be considered for certification. Additional time is required for site visit and determination if provider meets certification standards for agencies not nationally accredited. Failure to fully and accurately provide required information may increase certification time or result in non-certification. Provider certification is reviewed every three years. Evidence: (CPR, CSTAR, & TCM) State statute requires certification. The DBH Division, based on extensive experience in delivering quality behavioral health services, has determined that providers of CPR services should meet certain standards for staffing, administration, and service delivery that promote quality care for persons with serious mental illnesses. Practice guidelines support the rationale for this NQTL. TCM is supported by federal guidance. Appeal: (CPR, CSTAR, & TCM) Providers can appeal the decision if denied certification. If provider is denied certification or if their certification is revoked they may appeal to the Department Director. Then the provider's appeal is reviewed and a decision is made on the appeal. Provider has 30 days from the date of the notification of denial or revocation of certification to appeal to the Director. Provider must provide written notification/justification of appeal.

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Processes: (CPR) This is a certification standard which: - When a provider agency hires a staff person to perform services or functions that require the individual staff meet staff requirements for applicable services. The agency assure persons used as QMHPs, Peer Supports in the CPR program meet one of the categories of staff specified in state regulations. This may include primary source verification of educational degree, license, or certification. -Requires CPR provider agencies have a process for granting and periodically reviewing clinical privileges to staff and establishes minimum elements for that process. When new staff are hired the agency must go through a process to grant clinical privileges for staff delivering services; and clinical privileges must be reviewed and renewed at a minimum every two (2) years. This is a process carried out by provider agencies, and they may develop their own forms to guide and support this. Agencies may require additional approval to perform certain services in addition to certification.

Access Crisis Intervention Programs (CPR): This NQTL applies to both adults and children and youth. State regulation requires that providers meet minimum staffing requirements for their ACI system for both the 24 hour crisis hotline and the mobile crisis response. Staff are required to have certain qualifications and experience, and trained appropriately. When a person is hired to work in the ACI system, that triggers the provider agency must go through a process that insures the person meets certain qualifications and is trained appropriately. There is also a requirement for continuing education and training with minimum hours that must be completed annually and within a two (2) year period. The provider agency may develop forms to guide and document this process at their discretion.

Intensive CPR – Residential (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR. It limits provider agencies operating the Intensive CPR Residential service to only those who operate CPR programs, and are approved for the service by DMH. It also requires that the clients receiving this service are enrolled in the rehabilitation level of care. The trigger is when a provider agency wants to become a provider of these services, and when they want to start enrolling clients. When a provider agency wants to start providing this service they must notify DMH, DBH Division, and receive approval to deliver the service. Then when they enroll clients to be served, the provider must assure they are enrolled in the correct level of care. The team of staff that provide these services must be trained to provide the services and must be supervised by the QMHP.

Peer Support (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. It sets forth the staff qualifications and service definition for Certified Missouri Peer Specialists who deliver peer support services. When a provider agency wants to employ a person to provide peer support services, they must assure the person has at least a high school diploma or equivalent and has received the required training and passed the test in order to be a Certified Missouri Peer Specialist.

Psychosocial Rehabilitation (CPR): When an agency develops a psychosocial rehabilitation (PSR) program they must have that program either accredited by CARF, or licensed as a day program by DMH under licensure regulations. This NQTL further directs that if certification standards are more restrictive than licensure standards, then certification standards should prevail. Further, it limits the person assigned as the director of the adult PSR program must be a qualified mental health professional. For the youth PSR program the director of the program must be a qualified mental health professional with at least two (2) years of relevant work experience. This is in the Missouri Medicaid Provider Manual for CPR and sets limitations on how many persons can be served in an adult PSR program in relation to staffing. Staff to client ratios may not exceed 1:16; program needs or client mix may require even lower staff to client ratios; and at least one (1) staff person must be present at all times at the program site. When provider agencies are planning staffing coverage for a PSR program, they need to assure they have adequate staffing to meet these requirements.

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These are requirements in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. One (1) full time equivalent mental health professional shall be available during the provision of services. The staffing ratios shall be based on the client’s age. For those clients between the ages of three (3) and 11, the staffing ratio shall be one (1) staff to four (4) clients. For those clients between the ages of 12 and 17, the staffing ratio shall be one (1) staff to six (6) clients. Other staff of the PSR team shall be composed of the following providers as needed by the children: 1. a registered nurse; 2. an occupational therapist; 3. a recreational therapist; 4. a rehabilitation therapist; 5. a community support specialist; or, 6. family assistance worker.

Individual and Group Counseling PSR (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. It sets forth the staff qualifications and training requirements for persons providing Individual and Group Professional PSR. It is required that whenever a provider agency hires a staff person to provide Individual and Group Professional PSR, they must assure the person hired meets one of the staffing qualifications and has received the required training in mental health services. Qualified staff must be a professional counselor licensed or provisionally licensed under Missouri law and with specialized training in mental health services; or, a clinical social worker licensed or master social worker licensed under Missouri law and with specialized training in mental health services; or, a psychologist licensed or provisionally licensed or temporary licensed under Missouri law with specialized training in mental health services. Staff providing individual and group professional psychosocial rehabilitation services must have additional initial training such as, cognitive behavioral therapy, creating a recovery based mental treatment plan, Illness management and recovery, motivational interviewing, and introduction to DBT.

PSR – IMR (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. This limits providers of the PSR-IMR service to only those who have been approved by the DBH Division. Providers must submit in writing to the division a plan to implement this service along with planned curriculum, in order to get approval. The trigger is when a provider agency decides to implement this service for the first time, or to add new curriculum to a PSR-IMR program already operating.

Co-Occurring Services (CPR): This is a requirement in the CPR state regulation, regarding qualified staff who work in Integrated Dual Disorders Treatment (IDDT) programs. This sets forth minimum requirements for a person to be considered a QMHP or Qualified Addiction Professional (QAP) and meet co-occurring counselor competency requirements established by DBH. When an agency hires a person for a QAP position in an IDDT program, they must assure they meet one of the two qualification types above. This is a requirement in the CPR state regulation regarding fidelity reviews and quality improvement plans in Integrated Dual Disorders Treatment (IDDT) programs. Agencies delivering these services are required to follow the SAMHSA evidence based guidelines for IDDT, are required to receive fidelity reviews from the DBH Division, and are required to have a quality improvement plan as specified above. The trigger is an agency starting to implement an IDDT program, and annually thereafter when fidelity reviews come due. DBH staff utilize a standardized tool and form in fidelity reviews. It is required that agencies receive a fidelity review initially and annually thereafter. In addition the provider agency must develop and maintain a quality improvement plan that meets certain requirements in the regulation. DBH Division staff who conduct fidelity reviews must be trained and knowledgeable in IDDT.

Co-Occurring Services - Individual Counseling, Group Counseling, Group Education, and Co-Occurring Assessment Supplement (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. This establishes who an eligible staff person is to provide Co-Occurring Individual Counseling, Co-Occurring Group Counseling, Co-Occurring Group Education and Co-Occurring Assessment Supplement in an IDDT program. When a provider agency hires a person to deliver Co-Occurring Individual Counseling, Co-Occurring Group Counseling, and Co-Occurring Assessment Supplement in an IDDT program, they must assure the person is either a QMHP or a Qualified Addiction Professional (QAP), and meet co- occurring counselor competency requirements established by DMH. When a provider agency hires a person to deliver Co-Occurring Group Education in an IDDT program, they must assure the person has documented education and experience related to the topic presented and either be or be supervised by a

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QMHP or a QAP who meets co-occurring counselor competency requirements established by DMH.

Assertive Community Treatment (CPR): This is in state regulation and establishes minimum staffing requirements for Assertive Community Treatment (ACT) teams. When a provider agency hires staff for their ACT teams they must assure those staff meet requirements as follows:  The team shall have adequate nursing capacity by meeting one (1) of the following: o A registered professional nurse with six (6) months of psychiatric nursing experience shall work with no more than fifty (50) individuals on a full- time basis during the first year of program operation o During the first year of program operation, a registered professional nurse shall work with no more than fifty (50) individuals as a seventy-five percent (75%) Full-Time Equivalent (FTE) for up to twelve (12) months;  A team leader who is a qualified mental health professional as defined in 9 CSR 30-4.030(2)(HH) that is full time with one (1) year of supervisory experience and a minimum of two (2) years of experience working with adults with serious mental illness in community settings;  The team shall have adequate substance abuse treatment capacity by meeting one (1) of the following: 1. A substance abuse specialist who is a qualified substance abuse professional (QSAP) as defined in 9 CSR 10-7.140(2)(RR)1. or 2. with one (1) year of training or supervised experience in substance abuse treatment shall be assigned to no more than fifty (50) individuals; or 2. If the QSAP is not assigned to a team full time or is assigned to a team with less than fifty (50) individuals, the QSAP shall attend at least two (2) team meetings per week; or 3. A QSAP who has less than one (1) year experience in Integrated Dual Disorders Treatment (IDDT) shall be actively acquiring twenty-four (24) hours of training in IDDT- specific content and receive supervision from experienced IDDT staff;  The team shall have adequate vocational specialization capacity by meeting one (1) of the following: o A vocational specialist who qualifies as a community support worker as defined in 9 CSR 30-4.034(2)(H)1. with one (1) year of experience and training in vocational rehabilitation and supported employment shall be available to no more than fifty (50) individuals; or o If the vocational specialist is not assigned to a team full time or is assigned to a team with less than fifty (50) individuals, the vocational specialist shall attend at least two (2) team meetings per week; or o A vocational specialist with six (6) months of vocational experience shall work with no more than fifty (50) individuals on a full-time basis during the first year of program operation;  The team shall include a peer specialist which shall be self-identified as a present or former primary consumer of mental health services; be assigned full time to a team and shall participate in the clinical responsibilities and functions of the team in providing direct services; and serve as a model, a support, and a resource for the team members and individuals being served by the first year of program operation. Peer specialists, at a minimum, shall meet the qualifications of a community support assistant as defined in 9 CSR 30-4.030(2)(P) and 9 CSR 30-4.034(2)(H)2.;  The team shall include a program assistant. A team of one hundred (100) individuals requires one (1) Full Time Equivalent (FTE) prorated based on team size. The program assistant shall have education and experience in human services or office management. The program assistant shall organize, coordinate, and monitor all non-clinical operations of the team including but not limited to the following: o Managing medical records; o Operating and coordinating the management information system; and o Triaging telephone calls and coordinating communication between the team and individuals receiving ACT services;  Other team members may be assigned to work exclusively with the team and must qualify as a community support worker or a qualified mental health professional as defined in 9 CSR 30-4.034 (2)(H)1. or 9 CSR 30-4.030(2)(HH); and  In addition to training required in 9 CSR 30-4.034, team members shall receive ongoing training relevant to ACT services.

Contract (CPR & TCM): This NQTL applies to both adults and children and youth. These requirements are in the Administrative Agent Master Contract

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agreement. Administrative Agents are required to operate CPR programs for adults and children and youth, and TCM programs for adults and children and youth.  Further, this NQTL requires that they employ one or more full time Community Mental Health Liaisons (CMHLs), and sets forth minimum qualifications and training requirements for a CMHL. These liaison positions shall be filled by experienced, qualified mental health professionals who are: (a) Trained in assessment and crisis intervention; (b) Knowledgeable about the local system of care including, but not limited to, the operation of the community providers, the Access Crisis Intervention (ACI) system, inpatient psychiatric resources, civil commitment procedures, and guardianship laws; and c. Knowledgeable about behavioral health disorders and co-occurring disorders.  Contractors are required to incorporate trauma informed approaches into service delivery. As the agency develops policies, procedures, and processes to assess and serve clients, they should be considering trauma informed approaches. It is required that administrative agents incorporate trauma informed approaches into service delivery that actively consider the likelihood of a consumers trauma experience.

(CSTAR) Initial certification request and/or renewal process for existing certification by a provider. In order for an agency to be a CSTAR provider they must submit an application to DBH requesting CSTAR certification; they must comply with applicable standards as stated in the rule in addition to program specific rules as stated in standards. Agency must then be approved by DMH as a CSTAR provider. This process needs to be done initially and then every three years, the provider will have to complete the DBH certification application. The organization must comply with the standards applicable to each program for which certification is being sought.

Staff vacancy, new service and/or service expansion triggers hiring of qualified professionals. Provider must be knowledgeable of staff qualifications for each service. The agencies must hire/train staff and supervise staff and ensure continuous eligibility for service provision. Qualified staff must be available before services can be delivered. The person responsible for ensuring qualified staff for a given service must be knowledgeable of the service requirements.

Provider must obtain primary source verification to determine potential staff's status to determine:  If the person is eligible to provide the service now or if the person is a student and not currently eligible through prior experience and/or education.  If the person meets the requirements of an: o Qualified Substance Abuse Professional  A physician or qualified mental health professional meeting the educational/experiential/supervision requirements for licensure as established by the Missouri Division of Professional Registration who has at least one year of full-time experience in the treatment or rehabilitation of persons with substance use disorders; or  A person meeting the educational/experiential/supervision requirements for certification or registration as a substance abuse professional by the Missouri Substance Abuse Professional Credentialing Board. o Associate Counselor  The associate counselor is a trainee that must meet requirements set forth by the Missouri Credentialing Board or the appropriate board of professional registration within the Department of Economic Development. o Licensed Mental Health Professional  Provisional licensure as a mental health professional will satisfy the licensure requirement for designation as a QAP, including the qualifications required to deliver trauma-related and co-occurring disorders-related services. However, all other requirements

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related to provider qualifications must be met and demonstrated. o Community Support Specialist  Must meet one of the following qualifications:  A mental health professional as defined in 9 CSR 10 – 7.140 (2) (QQ);  An individual with a bachelor’s degree in a human services field, which includes social work, psychology, nursing, education, criminal justice, recreational therapy, human development and family studies, counseling, child development, gerontology, sociology, human services, behavioral science and rehabilitation counseling;  An individual with any four year degree and two years of qualifying experience;  An individual with any four year combination of higher education and qualifying experience, or o An individual with four years of qualifying experience.  Qualifying experience must include delivery of service to individuals with mental illness, substance use disorder or developmental disabilities. Experience must include some combination of the following:  Providing one-on-one or group services with a rehabilitation/habilitation and recovery/resiliency focus;  Teaching and modeling for individuals how to cope and manage psychiatric, developmental or substance use issues while encouraging the use of natural resources;  Supporting efforts to find and maintain employment for individuals and/or to function appropriately in families, school and communities;  Assisting individuals to achieve the goals and objectives on their person centered individualized treatment plans.  It is also required that the Community Support Specialist complete the necessary orientation and training requirements specified by DMH. o Co-Occurring Counselor  Co-occurring disorder individual counseling is provided by either a person licensed by the Missouri Division of Professional Registration as a mental health professional who is practicing within their current competence; or, a person certified by the Missouri Credentialing Board as a professional working in co-occurring disorders who is practicing within their current competence. o Trauma Counselor  Trauma individual counseling is provided by a licensed mental health professional who is a qualified addiction professional (QAP). Qualified staff must have specialized trauma training and/or equivalent work experience and shall utilize an evidence-based treatment model for the delivery of this service.; or  Has the ability/training/etc. to provide: o Any CSTAR Service  Intake Assessment – Qualified Addiction Professional (reviews and interprets assessment data and meets with consumer to develop treatment recommendations), and licensed diagnostician (renders a five-axis diagnosis). Other components included in service description:  Outcome Measurement – Community Support Worker or Qualified Addiction Professional; and  Assessment and Diagnostic Update – Qualified Addiction Professional (reviews and interprets assessment data and meets with consumer to develop treatment recommendations), and licensed diagnostician (renders a five-axis diagnosis)  Community Support – Community Support Worker  Individual Counseling – Qualified Addiction Professional or Associate Counselor. Evidence based interventions requires Licensed Mental Health Professional that is a Qualified Addiction Professional with relevant training/experience or specific credentials.

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 Group Counseling – Qualified Addiction Professional or Associate Counselor  Group Therapeutic Substance Abuse Education – Individual with appropriate background, experience and knowledge and demonstrated competencies and skills  Day Treatment – Activities and interventions delivered under supervision of Qualified Addiction Professional  Family Therapy – Licensed or certified marriage and family therapist, or qualified professional as defined in 9 CSR 30-3.110(6)(D)  Codependency Counseling – Family Therapist or Qualified Addiction Professional with appropriate training  Detoxification Services – A team that includes a licensed physician or Advanced Practice Nurse, registered and licensed nursing staff and other specialty trained staff  Medication Services – Licensed Physician or Advanced Practice Nurse  Extended Day Treatment – Licensed, Registered Nurse o Group Therapeutic Substance Use Disorder Education  Group therapeutic substance use disorder education services shall be provided by an individual who:  Is suited by education, background or experience to teach the information being presented;  Demonstrates competency and skill in educational techniques;  Has knowledge of the topic(s) being taught; and,  Is present with participants throughout the group therapeutic substance use disorder education session.  In addition, staff who provide information about human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) shall have completed a department approved or comparable training program. o Trauma Group Education  Trauma group education must be provided by staff with specialized training in trauma and addiction. o Family Therapy  Unless otherwise approved and documented by DMH, family therapy shall be performed by a person who:  Is licensed in Missouri as a marital and family therapist; or  Is certified by the American Association of Marriage and Family Therapists; or  Has a graduate (doctoral or masters) degree in psychology, social work or counseling and has at least one year of supervised experience in family counseling and has specialized training in family counseling; or has a graduate (doctoral or masters) degree in psychology, social work or counseling and receives close supervision from an individual who meets the above requirements; or,  A degreed, qualified addiction professional who receives close supervision from an individual that meets the above requirements. o Collateral Dependent Counseling  Assessments, individual counseling and group counseling services provided to children under age 12 shall be provided by:  A social worker, counselor, psychologist or physician licensed in Missouri who has at least one year of full-time experience in the assessment and treatment of children; or,  A graduate of an accredited college or university with a master’s degree in social work, psychology, counseling, psychiatric nursing or closely related field, which has at least two years of full-time equivalent experience in the treatment and assessment of children. Group collateral dependent services for therapeutic substance use disorder education for children under age 12 shall be provided by a graduate of an accredited college or university with a bachelor's degree in counseling, psychology, social work or closely related field.

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o Individual and Group Counseling  A majority of the program’s staff who provide individual and group counseling shall be qualified substance abuse professionals. o Extended Day Treatment  This service consists of medical and other consultative services provided by a registered nurse for the purposes of monitoring and managing a participant’s health, and medication management.  A registered nurse (RN) with relevant education, experience, and competency is available on site or by phone for 24-hour supervision. o Opioid Treatment Program  When a person works in an Opioid Treatment setting the provider must provide or arrange and document ongoing training that consists of at least 14 hours of training for all staff working in an Opioid Treatment setting every 2 years. The provider must include in their HR processes a method to ensure trainings are occurring, staff are attending and training is documented with at least 14 hours of training every 2 years. o Adolescent Treatment Support  Service delivery staff shall:  Have training and demonstrate expertise regarding the treatment of both substance use disorders and other disorders related to adolescents; and,  Receive clinical supervision by an appropriately licensed, certified, or otherwise credentialed person with experience in the treatment of adolescents.  Participants shall be supervised at all times by a staff member with current certification in first aid and cardiopulmonary resuscitation. o Communicable Disease Counseling  Prior to being tested for HIV, counseling must be provided by individuals who are knowledgeable about communicable diseases including HIV, TB and STDs through training and/or previous employment experience.  Staff’s knowledge shall include awareness of risks, disease management/treatment and resources for care, and confidentiality requirements when working with special populations. Post-test counseling may be provided for those testing positive for either HIV or TB. Staff providing these services shall also be competent to therapeutically assist consumers to understand and appropriately respond to test results. Post-test counseling for HIV or TB must also be knowledgeable about services and care coordination available through the DHSS.  Supervision o Credentials for Supervisor of Counselors. Unless otherwise required by these rules, supervision of counselors must be provided by a qualified substance abuse professional who has  A degree from an accredited college in an approved field of study; or  Four (4) or more year’s employment experience in the treatment and rehabilitation of persons with substance abuse problems. o Credentials for Supervisor of Community Support Workers. A community support worker shall be supervised by an individual with  A master’s degree from an accredited college or university in social work, counseling, psychology or a closely related field and at least one (1) year of full-time equivalent experience in providing community support services; or  A bachelor’s degree from an accredited college or university in social work, counseling, psychology or a closely related field and at least two (2) years of full-time equivalent experience in providing community support services; and  Demonstrated competencies in the areas of supervision and substance abuse treatment and rehabilitation by virtue of experience

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and/or training.

Other Applicable Program Requirements. A CSTAR program shall meet the following additional requirements, when the department determines that they are applicable:  Services offered on a residential basis shall comply with requirements for residential treatment; and  Requirements as a specialized program for adolescents or as a specialized program for women and children shall be met, where applicable.

All detoxification services shall be provided in a humane manner and shall ensure the safety and well-being of persons served.  There shall be monitoring and assessment of the person’s physical and emotional status during the detoxification process. o Vital signs shall be taken on a regular basis, with the frequency determined by client need based on a standardized assessment instrument. o Blood alcohol concentration may be monitored upon admission and thereafter as indicated. Further testing of urine or blood may be conducted by qualified personnel.  Staff coverage in residential settings shall ensure the continuous supervision and safety of clients. o Two (2) staff members shall be on-site at all times, and additional staff may be required, as warranted by the size of the program and the responsibilities and duties of staff members. o Staff providing direct supervision and monitoring of clients shall demonstrate competency in recognizing symptoms of intoxication, impairment and withdrawal; monitoring vital signs; and understanding basic principles and resources for substance abuse treatment. o Clients shall be supervised at all times by a staff member with current certification in first aid and cardiopulmonary resuscitation. When the Department notifies providers of newly required training, the provider would ensure staff received the required training and document training within the timeframe set by the Department. The providers must provide or arrange for their staff to receive specified training.

If a religious entity contracts with DMH, the religious organization must meet the same requirements as non-religious organizations per block grant as well as comply with federal requirement pertaining to charitable choice provisions and regulations. (TCM) A provider of TCM services is an entity that is designated by the DMH. Designation is contingent upon the provision of the core services listed below. These services may be provided directly or by subcontract. The required service functions include the following:  Assessment and periodic reassessment  Case Coordination  Case Monitoring  Case Documentation  Supported Community Living (SCL) Functions TCM services are provided by community mental health facilities approved to provide this service by the Department of Mental Health. Administrative Agent of DMH hire and employs Targeted Case Managers and QMHP for the purpose of administration of TCM. Administrative agent verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Individual must meet requirement prior to rendering services.  Targeted Case Managers o For youth, must at a minimum be a graduate from an accredited four (4) year college or university with a specialization in sociology,

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psychology, social work, or closely related fields and at least one (1) year of full-time equivalent experience in working with children and families. o For adults, must have graduated from an accredited four (4) year college or university with a specialization in sociology, psychology, social work, or closely related fields or a graduate from an accredited four (4) year college or university with related work experience. Relevant human service delivery experience can be substituted on a year for year basis for the four year degree.  A qualified mental health professional (QMHP) for the purpose of administration of the MO HealthNet TCM, is defined as: o A physician licensed under Missouri law to practice medicine or osteopathy and with training in mental health services or one year of experience, under supervision, in treating problems related to mental illness and serious emotional disturbances. o A psychiatrist licensed under Missouri law as a physician and who has successfully completed a training program in psychiatry approved by the American Medical Association, the American Osteopathic Association, or other training program identified as equivalent by DMH. o A psychologist licensed under Missouri law to practice psychology with specialized training in mental health services. o A professional counselor licensed under Missouri law to practice counseling with specialized training in mental health services. o A clinical social worker licensed under Chapter 337 RSMo. o A psychiatric nurse licensed under Chapter 335 RSMo., as a registered professional nurse with at least two years of experience in a psychiatric or substance use disorder treatment setting or a master’s degree in psychiatric nursing. o An individual possessing a master’s or doctorate degree in counseling and guidance, vocational counseling, pastoral counseling, rehabilitation counseling and guidance, psychology, family therapy, or related field, who has successfully completed a practicum or has one year of experience under the supervision of a qualified mental health professional. o An occupational therapist certified by the American Occupational Therapy Certification Board, registered in Missouri, who has a bachelor’s degree and has completed a practicum in a psychiatric setting or has one year experience in a psychiatric setting or has a master’s degree and has completed either a practicum in a psychiatric setting or has one year of experience in a psychiatric setting. o An advanced practice nurse under Chapter 335.016 RSMo who has had education beyond the basic nursing education and is certified by a nationally recognized professional organization as having a nursing specialty, or who meets criteria for advanced practice nurses established by the board of nursing. o A psychiatric pharmacist who is a registered pharmacist in good standing with the Missouri Board of Pharmacy who is a board certified pharmacist (BCPP) through the Board of Pharmaceutical Specialties or a registered pharmacist currently in a psycho-pharmacy residency where the service has been supervised by a board certified psychiatric pharmacist.

(HCH) Provider initially must complete an application form. Enrollment forms must be completed in order for an individual to be part of a HCH. The HCH provider must complete specified forms and submit to DBH, including monthly implementation report and monthly status report, monthly hospitalization follow-up report in addition they have to complete an attestation and send to MO HealthNet to support the services were provided and they have to submit data to a contracted population health platform. Agencies must meet staffing requirements for HCH Directors, Nurse Care Managers, care coordinators and Primary Care Physician Consultants per the staffing memo. HCH organizations must also meet national accreditation standards for HCHs. They must maintain CPR certification and contract with DBH and fulfill all requirements such as participation in scheduled trainings, meetings/phone conferences/webinars and submission of data as required. (HCH) In order to be a CMHC HCH, the provider must be certified as a CPR provider and hold a contract with DBH/DMH. They have to apply to DBH to be a HCH and be approved based on staffing patterns and expected practices. The DBH then recognizes the organization as an adult and or youth HCH.

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Initial and renewal of recognition as CMHC HCH every 3 years.

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Submission and Staffing: (CPR) This requires that all personnel provided by contracted agencies have criminal background checks in accordance with state law. When a contracted provider agency hires a new staff person, it is required that staff at contracted agencies have background checks completed. Depending on the service there is also a requirement for continuing education, training with minimum hours that must be completed annually and within a two (2) year period and passing any applicable test. The provider agency may develop forms to guide and document this process at their discretion. Some services require a staff to client ratio. The provider must also complete a clinical privileges process for staff to assure they meet qualification and training requirements to provide those services. Clinical privileging process must be done initially and every 2 years for all staff providing CPR service.

(CSTAR) Provider verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Depending on the service there is also a requirement for continuing education, training with minimum hours that must be completed within a two (2) year period. Some services require a staff to client ratio.

(TCM) Administrative agent verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Individual must meet requirement prior to rendering services.

(HCH) Administrative agent verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Individual must meet requirement prior to rendering services. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Strategy: (CPR) The purpose is to assure: staff with service and management responsibility meet certain minimal standards; agencies have the staffing in place to provide quality services; and that persons providing behavioral health services have the qualifications and skills to provide services. Clinical efficacy and safety concerns are the primary factors.

(CSTAR) The purpose of this NQTL is to ensure staff are appropriately trained and qualified to provide services, stay abreast of and demonstrate competency regarding changes and evolving practices in the field. The state sets staff qualifications and competency requirements in order to ensure quality service provision for the delivery of culturally sensitive and evidenced based practices. Factors in determining the NQTL include safety, clinical efficacy, quality of care, and quality services. We want to ensure that the services being delivered are not doing more harm than good.

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(TCM) The purpose of this NQTL is to ensure services are responsive to the individual's full range of needs and to assure services are provided by a qualified professional operating within their scope of practice. Clinical efficacy, elasticity of demand, licensing and accreditation were considered when determining the NQTL.

(HCH) The purpose of the HCH is to provide better care coordination and chronic disease monitoring of individuals with serious mental illness or severe emotional disturbance ultimately reducing costs and decreasing mortality. The purpose of the organization's required certification, accreditation and data reporting is to ensure quality outcome measures are met. Eligibility and coverage confirmation; safety concerns; cost of treatment; variability in cost and quality; clinical efficacy. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Evidence: (CPR) General best practices, SAMSHA, practice guideline, national standards, stakeholder involvement

(CSTAR) General best practices, SAMSHA, practice guideline, national standards, stakeholder involvement

(TCM) CMS guidance and SSA as follows:

o CMS-2237-IFC(3) states "case management services are comprehensive and must include all of the following: assessment of an eligible individual (42 CFR 440.169(d)(1)); development of a specific care plan (42 CFR 440.169(d)(2)); referral to services (42 CFR 440.169(d)(3)); and monitoring activities (42 CFR 440.169(d)(4))." To allow for consistent monitoring, oversight and timely updates/revisions the criteria for the provider is reviewed every three years if provider is not accredited. If provider is accredited criteria is reviewed every 3 or 4 years depending on accreditation body standards. MO HealthNet TCM provider manual is reviewed and updated yearly. o

o Section 1905(a)(13) of the Social Security Act and 42 CFR §440.130(d) provide that States may cover rehabilitative services: “including any medical or remedial services (provided in a facility, a home, or other setting)recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level. CMS 2237 IFC requires states to specify provider qualifications. CMS guidance CMS-2237-IFC (7) states "When a target group consists solely of individuals with developmental disabilities or chronic mental illness, States my limit provider participation to specific persons or entities by setting forth qualifying criteria that assure the ability of the case managers to connect individuals with needed services". To allow for consistent monitoring of required staff qualifications, certification for the provider is reviewed every three years if provider is not accredited. If provider is accredited criteria is reviewed every 3 or 4 years depending on accrediting body standards. MO HealthNet TCM provider manual is reviewed and updated yearly.

(HCH) Published research-CATIE study that references that individuals with serious mental illness die 25 years younger than the general population due to preventable chronic diseases. DBH also utilizes population health data to determine target areas of treatment. DMH utilizes the data submitted to DBH from HCH providers to help providers focus their treatment. Criteria was developed by DBH along with stakeholders, including the Coalition of Behavioral

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Health Centers and providers. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Appeal: (All) DMH Exceptions Committee hears requests for waiver to a rule regarding staff qualifications for services.

State Compliance Determination Complies Follow up Doesn’t Comply Action:

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NQTL: Exclusions for Specific Types of Providers Health Plan/State: Missouri Care / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Missouri Care: N/A FFS: N/A

Compliance Analysis Missouri Care: Follows FFS policy regarding exclusion of licensed marital and family therapists from enrolling / network admission.

FFS: Licensed marital and family therapists are not enrolled as providers. Licensed clinical social workers may provide services to children in any setting, but services to adults are limited to FQHC, RHC, CMHC settings. Licensed professional counselors may provide services to children in any setting, but services to adults are limited to CCBHC.

State Compliance Determination Complies Follow up Doesn’t Comply Action: MHD is amending state plan to add these providers.

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NQTL: Network Admission Requirements: Provider Enrollment and Credentialing Health Plan/State: UnitedHealthcare / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers UnitedHealthcare – Inpatient and Outpatient: Applicable to all provider and practitioner types under consideration for network participation.

FFS (outpatient): CPR, CSTAR, Adult TCM, & Youth TCM, clinic option providers (for COA 4); Inpatient (COA 4 if behavioral health admission only)

UnitedHealthcare – Inpatient and Outpatient: Applicable to all provider and practitioner types under consideration for network participation.

FFS: Inpatient and Outpatient: Applicable to all provider and practitioner types during enrollment.

Compliance Analysis UnitedHealthcare: For both MH/SUD and M/S, providers must meet all credentialing criteria to be eligible for network participation. Participation criteria for practitioners include: 1. Education • Psychiatrists must have graduated from medical school and successful completion of either a residency program or other clinical training and experience for their specialty and scope of practice. • M.D.s and D.O.s: graduation from an allopathic or osteopathic medical school and successful completion of either a residency program or other clinical training and experience for their specialty and scope of practice. • Chiropractors: graduation from chiropractic college • Dentists: graduation from dental school

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• Non-physician providers must be: A doctoral and/or master’s level psychologist, social worker behavioral health care specialist or a Master’s level psychiatric clinical nurse, must be licensed to practice independently by the state in which they practice.

2. Licensing Applicants must maintain current, valid licensure or certification, without material restrictions, conditions or other disciplinary actions in all states where the applicant practices. 3. Admitting privileges For MH/SUD, hospital privileges are not required. However if applicant has hospital staff privileges, those privileges must be in good standing at a network hospital. Privileges at any hospital must not have been suspended during the past 12 months due to inappropriate, inadequate or tardy completion of medical records or for quality of care issues. For M/S, must have full hospital privileges, without material restrictions, conditions or other disciplinary action at a minimum of one Participating (Network) hospitals or arrangements with a Participating LIP to admit and provide hospital coverage to Covered Persons at a Participating (Network) hospital, if the Credentialing Entity determines that Applicant's practice requires such privileges.

4. Current and unrestricted DEA or Controlled Substance Certificate or acceptable substitute in each state where the Applicant practices (unless such Certificate is not required for the Applicant’s practice). 5. Medicare/Medicaid Program Participation Eligibility Must not be ineligible, excluded or debarred from participation in Medicare, Medicaid or other related state and federal programs, or terminated for cause from same, and must be without any sanctions levied by the Office of the Inspector General or General Services Administration or other disciplinary action by any federal or state entities identified by CMS. 6. Work History Must provide a 5 year employment history. Gaps longer than 6 months must be explained by the applicant and found acceptable by the credentialing committee. 7. Liability Insurance or state approved alternative 8. Site visits are completed when required by Credentialing Authorities The average length of time for the credentialing and re-credentialing process for both MH/SUD and M/S providers is within 60 business days from completed application received, per state requirements.

9. Network participation For both MH/SUD and M/S, applicant must not have been denied initial participation, or terminated within the preceding 24 months prior to application, or at any time during the term of the Provider Participation Agreement. (for reasons other than network need).

Participation Criteria for facilities include:

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• Must be licensed or certified by designated state agency as required by state law • Must have appropriate levels of malpractice insurance coverage • Must not be ineligible, excluded, or debarred from federal programs with no sanctions from OIG or GSA or any state licensing or oversight agency • Must have appropriate accreditation from a national or state accreditation body accepted by credentialing entity. If facility is not accredited, a site visit is required.

Practitioners and facilities are credentialed in timelines required by NCQA/CMS/ and state laws. Most stringent timeline requirement is applied.

Practitioners and facilities are recredentialed every three (3) years using the above criteria

State Specific Requirements: Credentialing entity is required to make a decision whether to approve or deny a practitioner’s credentialing application within 60 business days of receipt of completed credentialing application.

For MH/SUD and for M/S facilities, credentialing and recredentialing occur within 60 business days from completed application received date.

The purpose is to ensure properly qualified providers are delivering services to our members. Providers must meet certain levels of clinical competency and practice performance in order to maintain the quality and integrity of our network. UHC adheres to national accreditation and provider certification standards as required by NCQA, CMS and respective state laws. If there is no network provider who can provide the service and is within a reasonable travel distance from the member. Single case agreement will be allowed on 100% of Medicaid.

FFS – For MH/SUD and M/S, individual providers must submit copy of professional license and Medicare letter (if Medicare enrolled). For MH/SUD and M/S hospitals must be currently licensed by the Department of Health & Senior Services and Medicare certified as a

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hospital. Must submit a copy of the hospital license and Medicare certification letter.

DMH – Processes: (CPR, CSTAR & TCM) Provider agencies must be certified under both CPR and Core Rules state regulations in order to deliver and be reimbursed for CPR services by the Missouri Medicaid program, MO HealthNet. The DBH Division assures the agency has the ability and the qualified staff to deliver core services. The certification unit may make a site visit to determine if the agency meets certification standards, and/or require proof of other relevant accreditation status. If the provider is nationally accredited for behavioral health care from CARF International, The Joint Commission, or Council On Accreditation (COA) the department shall grant certification upon receipt of completed application and proof of national accreditation. Submission and Staffing: (CPR, CSTAR, & TCM) The steps for obtaining certification start with the provider agency completing a DBH certification application form and submitting that form to the DBH certification unit for review and approval. The form is submitted via mail, fax or electronically. The persons reviewing the DBH certification application form must meet the requirement as a Program Specialist and receive appropriate training which includes but is not limited to job shadowing, review of manuals, knowledge of standards, etc. Strategy: (CPR, CSTAR & TCM) To verify the provider agency applying for certification meet requirements in the Code of State Regulation that allows them to provide quality, effective services. Eligibility, safety, and quality care concerns are the primary factors in requiring that provider agencies seeking to provide services that meet certain minimal standards. Timeline: (CPR, CSTAR, & TCM) DBH certification unit has 30 days in which to determine whether the agency is eligible to be considered for certification. Additional time is required for site visit and determination if provider meets certification standards for agencies not nationally accredited. Failure to fully and accurately provide required information may increase certification time or result in non-certification. Provider certification is reviewed every three years. Evidence: (CPR, CSTAR, & TCM) State statute requires certification. The DBH Division, based on extensive experience in delivering quality behavioral health services, has determined that providers of CPR services should meet certain standards for staffing, administration, and service delivery that promote quality care for persons with serious mental illnesses. Practice guidelines support the rationale for this NQTL. TCM is supported by federal guidance. Appeal: (CPR, CSTAR, & TCM) Providers can appeal the decision if denied certification. If provider is denied certification or if their certification is revoked they may appeal to the Department Director. Then the provider's appeal is reviewed and a decision is made on the appeal. Provider has 30 days from the date of the notification of denial or revocation of certification to appeal to the Director. Provider must provide written notification/justification of appeal.

Processes: (CPR) This is a certification standard which: - When a provider agency hires a staff person to perform services or functions that require the individual staff meet staff requirements for applicable services. The agency assure persons used as QMHPs, Peer Supports in the CPR program meet one of the categories of staff specified in state regulations. This may include primary source verification of educational degree, license, or certification. -Requires CPR provider agencies have a process for granting and periodically reviewing clinical privileges to staff and establishes minimum elements for that process. When new staff are hired the agency must go through a process to grant clinical privileges for staff delivering services; and clinical privileges must be reviewed and renewed at a minimum every two (2) years. This is a process carried out by provider agencies, and they may develop their own forms to

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guide and support this. Agencies may require additional approval to perform certain services in addition to certification.

Access Crisis Intervention Programs (CPR): This NQTL applies to both adults and children and youth. State regulation requires that providers meet minimum staffing requirements for their ACI system for both the 24 hour crisis hotline and the mobile crisis response. Staff are required to have certain qualifications and experience, and trained appropriately. When a person is hired to work in the ACI system, that triggers the provider agency must go through a process that insures the person meets certain qualifications and is trained appropriately. There is also a requirement for continuing education and training with minimum hours that must be completed annually and within a two (2) year period. The provider agency may develop forms to guide and document this process at their discretion.

Intensive CPR – Residential (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR. It limits provider agencies operating the Intensive CPR Residential service to only those who operate CPR programs, and are approved for the service by DMH. It also requires that the clients receiving this service are enrolled in the rehabilitation level of care. The trigger is when a provider agency wants to become a provider of these services, and when they want to start enrolling clients. When a provider agency wants to start providing this service they must notify DMH, DBH Division, and receive approval to deliver the service. Then when they enroll clients to be served, the provider must assure they are enrolled in the correct level of care. The team of staff that provide these services must be trained to provide the services and must be supervised by the QMHP.

Peer Support (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. It sets forth the staff qualifications and service definition for Certified Missouri Peer Specialists who deliver peer support services. When a provider agency wants to employ a person to provide peer support services, they must assure the person has at least a high school diploma or equivalent and has received the required training and passed the test in order to be a Certified Missouri Peer Specialist.

Psychosocial Rehabilitation (CPR): When an agency develops a psychosocial rehabilitation (PSR) program they must have that program either accredited by CARF, or licensed as a day program by DMH under licensure regulations. This NQTL further directs that if certification standards are more restrictive than licensure standards, then certification standards should prevail. Further, it limits the person assigned as the director of the adult PSR program must be a qualified mental health professional. For the youth PSR program the director of the program must be a qualified mental health professional with at least two (2) years of relevant work experience. This is in the Missouri Medicaid Provider Manual for CPR and sets limitations on how many persons can be served in an adult PSR program in relation to staffing. Staff to client ratios may not exceed 1:16; program needs or client mix may require even lower staff to client ratios; and at least one (1) staff person must be present at all times at the program site. When provider agencies are planning staffing coverage for a PSR program, they need to assure they have adequate staffing to meet these requirements. These are requirements in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. One (1) full time equivalent mental health professional shall be available during the provision of services. The staffing ratios shall be based on the client’s age. For those clients between the ages of three (3) and 11, the staffing ratio shall be one (1) staff to four (4) clients. For those clients between the ages of 12 and 17, the staffing ratio shall be one (1) staff to six (6) clients. Other staff of the PSR team shall be composed of the following providers as needed by the children: 1. a registered nurse; 2. an occupational therapist; 3. a recreational therapist; 4. a rehabilitation therapist; 5. a community support specialist; or, 6. family assistance worker.

Individual and Group Counseling PSR (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. It sets forth the staff qualifications and training requirements for persons providing Individual and Group Professional PSR. It is required that whenever a provider agency hires a staff person to provide Individual and Group Professional PSR, they must assure the person hired meets one of the

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staffing qualifications and has received the required training in mental health services. Qualified staff must be a professional counselor licensed or provisionally licensed under Missouri law and with specialized training in mental health services; or, a clinical social worker licensed or master social worker licensed under Missouri law and with specialized training in mental health services; or, a psychologist licensed or provisionally licensed or temporary licensed under Missouri law with specialized training in mental health services. Staff providing individual and group professional psychosocial rehabilitation services must have additional initial training such as, cognitive behavioral therapy, creating a recovery based mental treatment plan, Illness management and recovery, motivational interviewing, and introduction to DBT.

PSR – IMR (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. This limits providers of the PSR-IMR service to only those who have been approved by the DBH Division. Providers must submit in writing to the division a plan to implement this service along with planned curriculum, in order to get approval. The trigger is when a provider agency decides to implement this service for the first time, or to add new curriculum to a PSR-IMR program already operating.

Co-Occurring Services (CPR): This is a requirement in the CPR state regulation, regarding qualified staff who work in Integrated Dual Disorders Treatment (IDDT) programs. This sets forth minimum requirements for a person to be considered a QMHP or Qualified Addiction Professional (QAP) and meet co-occurring counselor competency requirements established by DBH. When an agency hires a person for a QAP position in an IDDT program, they must assure they meet one of the two qualification types above. This is a requirement in the CPR state regulation regarding fidelity reviews and quality improvement plans in Integrated Dual Disorders Treatment (IDDT) programs. Agencies delivering these services are required to follow the SAMHSA evidence based guidelines for IDDT, are required to receive fidelity reviews from the DBH Division, and are required to have a quality improvement plan as specified above. The trigger is an agency starting to implement an IDDT program, and annually thereafter when fidelity reviews come due. DBH staff utilize a standardized tool and form in fidelity reviews. It is required that agencies receive a fidelity review initially and annually thereafter. In addition the provider agency must develop and maintain a quality improvement plan that meets certain requirements in the regulation. DBH Division staff who conduct fidelity reviews must be trained and knowledgeable in IDDT.

Co-Occurring Services - Individual Counseling, Group Counseling, Group Education, and Co-Occurring Assessment Supplement (CPR): This is a requirement in the Missouri Medicaid Provider Manual for CPR, and also in CPR state regulations. This establishes who an eligible staff person is to provide Co-Occurring Individual Counseling, Co-Occurring Group Counseling, Co-Occurring Group Education and Co-Occurring Assessment Supplement in an IDDT program. When a provider agency hires a person to deliver Co-Occurring Individual Counseling, Co-Occurring Group Counseling, and Co-Occurring Assessment Supplement in an IDDT program, they must assure the person is either a QMHP or a Qualified Addiction Professional (QAP), and meet co- occurring counselor competency requirements established by DMH. When a provider agency hires a person to deliver Co-Occurring Group Education in an IDDT program, they must assure the person has documented education and experience related to the topic presented and either be or be supervised by a QMHP or a QAP who meets co-occurring counselor competency requirements established by DMH.

Assertive Community Treatment (CPR): This is in state regulation and establishes minimum staffing requirements for Assertive Community Treatment (ACT) teams. When a provider agency hires staff for their ACT teams they must assure those staff meet requirements as follows:  The team shall have adequate nursing capacity by meeting one (1) of the following: o A registered professional nurse with six (6) months of psychiatric nursing experience shall work with no more than fifty (50) individuals on a full- time basis during the first year of program operation o During the first year of program operation, a registered professional nurse shall work with no more than fifty (50) individuals as a seventy-five

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percent (75%) Full-Time Equivalent (FTE) for up to twelve (12) months;  A team leader who is a qualified mental health professional as defined in 9 CSR 30-4.030(2)(HH) that is full time with one (1) year of supervisory experience and a minimum of two (2) years of experience working with adults with serious mental illness in community settings;  The team shall have adequate substance abuse treatment capacity by meeting one (1) of the following: 1. A substance abuse specialist who is a qualified substance abuse professional (QSAP) as defined in 9 CSR 10-7.140(2)(RR)1. or 2. with one (1) year of training or supervised experience in substance abuse treatment shall be assigned to no more than fifty (50) individuals; or 2. If the QSAP is not assigned to a team full time or is assigned to a team with less than fifty (50) individuals, the QSAP shall attend at least two (2) team meetings per week; or 3. A QSAP who has less than one (1) year experience in Integrated Dual Disorders Treatment (IDDT) shall be actively acquiring twenty-four (24) hours of training in IDDT- specific content and receive supervision from experienced IDDT staff;  The team shall have adequate vocational specialization capacity by meeting one (1) of the following: o A vocational specialist who qualifies as a community support worker as defined in 9 CSR 30-4.034(2)(H)1. with one (1) year of experience and training in vocational rehabilitation and supported employment shall be available to no more than fifty (50) individuals; or o If the vocational specialist is not assigned to a team full time or is assigned to a team with less than fifty (50) individuals, the vocational specialist shall attend at least two (2) team meetings per week; or o A vocational specialist with six (6) months of vocational experience shall work with no more than fifty (50) individuals on a full-time basis during the first year of program operation;  The team shall include a peer specialist which shall be self-identified as a present or former primary consumer of mental health services; be assigned full time to a team and shall participate in the clinical responsibilities and functions of the team in providing direct services; and serve as a model, a support, and a resource for the team members and individuals being served by the first year of program operation. Peer specialists, at a minimum, shall meet the qualifications of a community support assistant as defined in 9 CSR 30-4.030(2)(P) and 9 CSR 30-4.034(2)(H)2.;  The team shall include a program assistant. A team of one hundred (100) individuals requires one (1) Full Time Equivalent (FTE) prorated based on team size. The program assistant shall have education and experience in human services or office management. The program assistant shall organize, coordinate, and monitor all non-clinical operations of the team including but not limited to the following: o Managing medical records; o Operating and coordinating the management information system; and o Triaging telephone calls and coordinating communication between the team and individuals receiving ACT services;  Other team members may be assigned to work exclusively with the team and must qualify as a community support worker or a qualified mental health professional as defined in 9 CSR 30-4.034 (2)(H)1. or 9 CSR 30-4.030(2)(HH); and  In addition to training required in 9 CSR 30-4.034, team members shall receive ongoing training relevant to ACT services.

Contract (CPR & TCM): This NQTL applies to both adults and children and youth. These requirements are in the Administrative Agent Master Contract agreement. Administrative Agents are required to operate CPR programs for adults and children and youth, and TCM programs for adults and children and youth.  Further, this NQTL requires that they employ one or more full time Community Mental Health Liaisons (CMHLs), and sets forth minimum qualifications and training requirements for a CMHL. These liaison positions shall be filled by experienced, qualified mental health professionals who are: (a) Trained in assessment and crisis intervention; (b) Knowledgeable about the local system of care including, but not limited to, the operation of the community providers, the Access Crisis Intervention (ACI) system, inpatient psychiatric resources, civil commitment procedures, and guardianship laws; and c. Knowledgeable about behavioral health disorders and co-occurring disorders.  Contractors are required to incorporate trauma informed approaches into service delivery. As the agency develops policies, procedures, and

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processes to assess and serve clients, they should be considering trauma informed approaches. It is required that administrative agents incorporate trauma informed approaches into service delivery that actively consider the likelihood of a consumers trauma experience.

(CSTAR) Initial certification request and/or renewal process for existing certification by a provider. In order for an agency to be a CSTAR provider they must submit an application to DBH requesting CSTAR certification; they must comply with applicable standards as stated in the rule in addition to program specific rules as stated in standards. Agency must then be approved by DMH as a CSTAR provider. This process needs to be done initially and then every three years, the provider will have to complete the DBH certification application. The organization must comply with the standards applicable to each program for which certification is being sought.

Staff vacancy, new service and/or service expansion triggers hiring of qualified professionals. Provider must be knowledgeable of staff qualifications for each service. The agencies must hire/train staff and supervise staff and ensure continuous eligibility for service provision. Qualified staff must be available before services can be delivered. The person responsible for ensuring qualified staff for a given service must be knowledgeable of the service requirements.

Provider must obtain primary source verification to determine potential staff's status to determine:  If the person is eligible to provide the service now or if the person is a student and not currently eligible through prior experience and/or education.  If the person meets the requirements of an: o Qualified Substance Abuse Professional  A physician or qualified mental health professional meeting the educational/experiential/supervision requirements for licensure as established by the Missouri Division of Professional Registration who has at least one year of full-time experience in the treatment or rehabilitation of persons with substance use disorders; or  A person meeting the educational/experiential/supervision requirements for certification or registration as a substance abuse professional by the Missouri Substance Abuse Professional Credentialing Board. o Associate Counselor  The associate counselor is a trainee that must meet requirements set forth by the Missouri Credentialing Board or the appropriate board of professional registration within the Department of Economic Development. o Licensed Mental Health Professional  Provisional licensure as a mental health professional will satisfy the licensure requirement for designation as a QAP, including the qualifications required to deliver trauma-related and co-occurring disorders-related services. However, all other requirements related to provider qualifications must be met and demonstrated. o Community Support Specialist  Must meet one of the following qualifications:  A mental health professional as defined in 9 CSR 10 – 7.140 (2) (QQ);  An individual with a bachelor’s degree in a human services field, which includes social work, psychology, nursing, education, criminal justice, recreational therapy, human development and family studies, counseling, child development, gerontology, sociology, human services, behavioral science and rehabilitation counseling;  An individual with any four year degree and two years of qualifying experience;  An individual with any four year combination of higher education and qualifying experience, or

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o An individual with four years of qualifying experience.  Qualifying experience must include delivery of service to individuals with mental illness, substance use disorder or developmental disabilities. Experience must include some combination of the following:  Providing one-on-one or group services with a rehabilitation/habilitation and recovery/resiliency focus;  Teaching and modeling for individuals how to cope and manage psychiatric, developmental or substance use issues while encouraging the use of natural resources;  Supporting efforts to find and maintain employment for individuals and/or to function appropriately in families, school and communities;  Assisting individuals to achieve the goals and objectives on their person centered individualized treatment plans.  It is also required that the Community Support Specialist complete the necessary orientation and training requirements specified by DMH. o Co-Occurring Counselor  Co-occurring disorder individual counseling is provided by either a person licensed by the Missouri Division of Professional Registration as a mental health professional who is practicing within their current competence; or, a person certified by the Missouri Credentialing Board as a professional working in co-occurring disorders who is practicing within their current competence. o Trauma Counselor  Trauma individual counseling is provided by a licensed mental health professional who is a qualified addiction professional (QAP). Qualified staff must have specialized trauma training and/or equivalent work experience and shall utilize an evidence-based treatment model for the delivery of this service.; or  Has the ability/training/etc. to provide: o Any CSTAR Service  Intake Assessment – Qualified Addiction Professional (reviews and interprets assessment data and meets with consumer to develop treatment recommendations), and licensed diagnostician (renders a five-axis diagnosis). Other components included in service description:  Outcome Measurement – Community Support Worker or Qualified Addiction Professional; and  Assessment and Diagnostic Update – Qualified Addiction Professional (reviews and interprets assessment data and meets with consumer to develop treatment recommendations), and licensed diagnostician (renders a five-axis diagnosis)  Community Support – Community Support Worker  Individual Counseling – Qualified Addiction Professional or Associate Counselor. Evidence based interventions requires Licensed Mental Health Professional that is a Qualified Addiction Professional with relevant training/experience or specific credentials.  Group Counseling – Qualified Addiction Professional or Associate Counselor  Group Therapeutic Substance Abuse Education – Individual with appropriate background, experience and knowledge and demonstrated competencies and skills  Day Treatment – Activities and interventions delivered under supervision of Qualified Addiction Professional  Family Therapy – Licensed or certified marriage and family therapist, or qualified professional as defined in 9 CSR 30-3.110(6)(D)  Codependency Counseling – Family Therapist or Qualified Addiction Professional with appropriate training  Detoxification Services – A team that includes a licensed physician or Advanced Practice Nurse, registered and licensed nursing staff and other specialty trained staff  Medication Services – Licensed Physician or Advanced Practice Nurse

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 Extended Day Treatment – Licensed, Registered Nurse o Group Therapeutic Substance Use Disorder Education  Group therapeutic substance use disorder education services shall be provided by an individual who:  Is suited by education, background or experience to teach the information being presented;  Demonstrates competency and skill in educational techniques;  Has knowledge of the topic(s) being taught; and,  Is present with participants throughout the group therapeutic substance use disorder education session.  In addition, staff who provide information about human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) shall have completed a department approved or comparable training program. o Trauma Group Education  Trauma group education must be provided by staff with specialized training in trauma and addiction. o Family Therapy  Unless otherwise approved and documented by DMH, family therapy shall be performed by a person who:  Is licensed in Missouri as a marital and family therapist; or  Is certified by the American Association of Marriage and Family Therapists; or  Has a graduate (doctoral or masters) degree in psychology, social work or counseling and has at least one year of supervised experience in family counseling and has specialized training in family counseling; or has a graduate (doctoral or masters) degree in psychology, social work or counseling and receives close supervision from an individual who meets the above requirements; or,  A degreed, qualified addiction professional who receives close supervision from an individual that meets the above requirements. o Collateral Dependent Counseling  Assessments, individual counseling and group counseling services provided to children under age 12 shall be provided by:  A social worker, counselor, psychologist or physician licensed in Missouri who has at least one year of full-time experience in the assessment and treatment of children; or,  A graduate of an accredited college or university with a master’s degree in social work, psychology, counseling, psychiatric nursing or closely related field, which has at least two years of full-time equivalent experience in the treatment and assessment of children. Group collateral dependent services for therapeutic substance use disorder education for children under age 12 shall be provided by a graduate of an accredited college or university with a bachelor's degree in counseling, psychology, social work or closely related field. o Individual and Group Counseling  A majority of the program’s staff who provide individual and group counseling shall be qualified substance abuse professionals. o Extended Day Treatment  This service consists of medical and other consultative services provided by a registered nurse for the purposes of monitoring and managing a participant’s health, and medication management.  A registered nurse (RN) with relevant education, experience, and competency is available on site or by phone for 24-hour supervision. o Opioid Treatment Program  When a person works in an Opioid Treatment setting the provider must provide or arrange and document ongoing training that

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consists of at least 14 hours of training for all staff working in an Opioid Treatment setting every 2 years. The provider must include in their HR processes a method to ensure trainings are occurring, staff are attending and training is documented with at least 14 hours of training every 2 years. o Adolescent Treatment Support  Service delivery staff shall:  Have training and demonstrate expertise regarding the treatment of both substance use disorders and other disorders related to adolescents; and,  Receive clinical supervision by an appropriately licensed, certified, or otherwise credentialed person with experience in the treatment of adolescents.  Participants shall be supervised at all times by a staff member with current certification in first aid and cardiopulmonary resuscitation. o Communicable Disease Counseling  Prior to being tested for HIV, counseling must be provided by individuals who are knowledgeable about communicable diseases including HIV, TB and STDs through training and/or previous employment experience.  Staff’s knowledge shall include awareness of risks, disease management/treatment and resources for care, and confidentiality requirements when working with special populations. Post-test counseling may be provided for those testing positive for either HIV or TB. Staff providing these services shall also be competent to therapeutically assist consumers to understand and appropriately respond to test results. Post-test counseling for HIV or TB must also be knowledgeable about services and care coordination available through the DHSS.  Supervision o Credentials for Supervisor of Counselors. Unless otherwise required by these rules, supervision of counselors must be provided by a qualified substance abuse professional who has  A degree from an accredited college in an approved field of study; or  Four (4) or more year’s employment experience in the treatment and rehabilitation of persons with substance abuse problems. o Credentials for Supervisor of Community Support Workers. A community support worker shall be supervised by an individual with  A master’s degree from an accredited college or university in social work, counseling, psychology or a closely related field and at least one (1) year of full-time equivalent experience in providing community support services; or  A bachelor’s degree from an accredited college or university in social work, counseling, psychology or a closely related field and at least two (2) years of full-time equivalent experience in providing community support services; and  Demonstrated competencies in the areas of supervision and substance abuse treatment and rehabilitation by virtue of experience and/or training.

Other Applicable Program Requirements. A CSTAR program shall meet the following additional requirements, when the department determines that they are applicable:  Services offered on a residential basis shall comply with requirements for residential treatment; and  Requirements as a specialized program for adolescents or as a specialized program for women and children shall be met, where applicable.

All detoxification services shall be provided in a humane manner and shall ensure the safety and well-being of persons served.

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 There shall be monitoring and assessment of the person’s physical and emotional status during the detoxification process. o Vital signs shall be taken on a regular basis, with the frequency determined by client need based on a standardized assessment instrument. o Blood alcohol concentration may be monitored upon admission and thereafter as indicated. Further testing of urine or blood may be conducted by qualified personnel.  Staff coverage in residential settings shall ensure the continuous supervision and safety of clients. o Two (2) staff members shall be on-site at all times, and additional staff may be required, as warranted by the size of the program and the responsibilities and duties of staff members. o Staff providing direct supervision and monitoring of clients shall demonstrate competency in recognizing symptoms of intoxication, impairment and withdrawal; monitoring vital signs; and understanding basic principles and resources for substance abuse treatment. o Clients shall be supervised at all times by a staff member with current certification in first aid and cardiopulmonary resuscitation. When the Department notifies providers of newly required training, the provider would ensure staff received the required training and document training within the timeframe set by the Department. The providers must provide or arrange for their staff to receive specified training.

If a religious entity contracts with DMH, the religious organization must meet the same requirements as non-religious organizations per block grant as well as comply with federal requirement pertaining to charitable choice provisions and regulations. (TCM) A provider of TCM services is an entity that is designated by the DMH. Designation is contingent upon the provision of the core services listed below. These services may be provided directly or by subcontract. The required service functions include the following:  Assessment and periodic reassessment  Case Coordination  Case Monitoring  Case Documentation  Supported Community Living (SCL) Functions TCM services are provided by community mental health facilities approved to provide this service by the Department of Mental Health. Administrative Agent of DMH hire and employs Targeted Case Managers and QMHP for the purpose of administration of TCM. Administrative agent verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Individual must meet requirement prior to rendering services.  Targeted Case Managers o For youth, must at a minimum be a graduate from an accredited four (4) year college or university with a specialization in sociology, psychology, social work, or closely related fields and at least one (1) year of full-time equivalent experience in working with children and families. o For adults, must have graduated from an accredited four (4) year college or university with a specialization in sociology, psychology, social work, or closely related fields or a graduate from an accredited four (4) year college or university with related work experience. Relevant human service delivery experience can be substituted on a year for year basis for the four year degree.  A qualified mental health professional (QMHP) for the purpose of administration of the MO HealthNet TCM, is defined as: o A physician licensed under Missouri law to practice medicine or osteopathy and with training in mental health services or one year of experience, under supervision, in treating problems related to mental illness and serious emotional disturbances. o A psychiatrist licensed under Missouri law as a physician and who has successfully completed a training program in psychiatry approved by

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the American Medical Association, the American Osteopathic Association, or other training program identified as equivalent by DMH. o A psychologist licensed under Missouri law to practice psychology with specialized training in mental health services. o A professional counselor licensed under Missouri law to practice counseling with specialized training in mental health services. o A clinical social worker licensed under Chapter 337 RSMo. o A psychiatric nurse licensed under Chapter 335 RSMo., as a registered professional nurse with at least two years of experience in a psychiatric or substance use disorder treatment setting or a master’s degree in psychiatric nursing. o An individual possessing a master’s or doctorate degree in counseling and guidance, vocational counseling, pastoral counseling, rehabilitation counseling and guidance, psychology, family therapy, or related field, who has successfully completed a practicum or has one year of experience under the supervision of a qualified mental health professional. o An occupational therapist certified by the American Occupational Therapy Certification Board, registered in Missouri, who has a bachelor’s degree and has completed a practicum in a psychiatric setting or has one year experience in a psychiatric setting or has a master’s degree and has completed either a practicum in a psychiatric setting or has one year of experience in a psychiatric setting. o An advanced practice nurse under Chapter 335.016 RSMo who has had education beyond the basic nursing education and is certified by a nationally recognized professional organization as having a nursing specialty, or who meets criteria for advanced practice nurses established by the board of nursing. o A psychiatric pharmacist who is a registered pharmacist in good standing with the Missouri Board of Pharmacy who is a board certified pharmacist (BCPP) through the Board of Pharmaceutical Specialties or a registered pharmacist currently in a psycho-pharmacy residency where the service has been supervised by a board certified psychiatric pharmacist.

(HCH) Provider initially must complete an application form. Enrollment forms must be completed in order for an individual to be part of a HCH. The HCH provider must complete specified forms and submit to DBH, including monthly implementation report and monthly status report, monthly hospitalization follow-up report in addition they have to complete an attestation and send to MO HealthNet to support the services were provided and they have to submit data to a contracted population health platform. Agencies must meet staffing requirements for HCH Directors, Nurse Care Managers, care coordinators and Primary Care Physician Consultants per the staffing memo. HCH organizations must also meet national accreditation standards for HCHs. They must maintain CPR certification and contract with DBH and fulfill all requirements such as participation in scheduled trainings, meetings/phone conferences/webinars and submission of data as required. (HCH) In order to be a CMHC HCH, the provider must be certified as a CPR provider and hold a contract with DBH/DMH. They have to apply to DBH to be a HCH and be approved based on staffing patterns and expected practices. The DBH then recognizes the organization as an adult and or youth HCH.

Initial and renewal of recognition as CMHC HCH every 3 years.

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Submission and Staffing: (CPR) This requires that all personnel provided by contracted agencies have criminal background checks in accordance with state law. When a contracted provider agency hires a new staff person, it is required that staff at contracted agencies have background checks completed. Depending on the service

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there is also a requirement for continuing education, training with minimum hours that must be completed annually and within a two (2) year period and passing any applicable test. The provider agency may develop forms to guide and document this process at their discretion. Some services require a staff to client ratio. The provider must also complete a clinical privileges process for staff to assure they meet qualification and training requirements to provide those services. Clinical privileging process must be done initially and every 2 years for all staff providing CPR service.

(CSTAR) Provider verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Depending on the service there is also a requirement for continuing education, training with minimum hours that must be completed within a two (2) year period. Some services require a staff to client ratio.

(TCM) Administrative agent verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Individual must meet requirement prior to rendering services.

(HCH) Administrative agent verifies proof of education, licensure and previous work experience, as well as maintain personnel records (i.e. maintain copies of proof of education, licensure and past work experience in personnel file/records). Individual must meet requirement prior to rendering services. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Strategy: (CPR) The purpose is to assure: staff with service and management responsibility meet certain minimal standards; agencies have the staffing in place to provide quality services; and that persons providing behavioral health services have the qualifications and skills to provide services. Clinical efficacy and safety concerns are the primary factors.

(CSTAR) The purpose of this NQTL is to ensure staff are appropriately trained and qualified to provide services, stay abreast of and demonstrate competency regarding changes and evolving practices in the field. The state sets staff qualifications and competency requirements in order to ensure quality service provision for the delivery of culturally sensitive and evidenced based practices. Factors in determining the NQTL include safety, clinical efficacy, quality of care, and quality services. We want to ensure that the services being delivered are not doing more harm than good.

(TCM) The purpose of this NQTL is to ensure services are responsive to the individual's full range of needs and to assure services are provided by a qualified professional operating within their scope of practice. Clinical efficacy, elasticity of demand, licensing and accreditation were considered when determining the NQTL.

(HCH) The purpose of the HCH is to provide better care coordination and chronic disease monitoring of individuals with serious mental illness or severe emotional disturbance ultimately reducing costs and decreasing mortality. The purpose of the organization's required certification, accreditation and data reporting is to ensure quality outcome measures are met. Eligibility and coverage confirmation; safety concerns; cost of treatment; variability in cost and

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quality; clinical efficacy. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Evidence: (CPR) General best practices, SAMSHA, practice guideline, national standards, stakeholder involvement

(CSTAR) General best practices, SAMSHA, practice guideline, national standards, stakeholder involvement

(TCM) CMS guidance and SSA as follows: o CMS-2237-IFC(3) states "case management services are comprehensive and must include all of the following: assessment of an eligible individual (42 CFR 440.169(d)(1)); development of a specific care plan (42 CFR 440.169(d)(2)); referral to services (42 CFR 440.169(d)(3)); and monitoring activities (42 CFR 440.169(d)(4))." To allow for consistent monitoring, oversight and timely updates/revisions the criteria for the provider is reviewed every three years if provider is not accredited. If provider is accredited criteria is reviewed every 3 or 4 years depending on accreditation body standards. MO HealthNet TCM provider manual is reviewed and updated yearly. o Section 1905(a)(13) of the Social Security Act and 42 CFR §440.130(d) provide that States may cover rehabilitative services: “including any medical or remedial services (provided in a facility, a home, or other setting)recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level. CMS 2237 IFC requires states to specify provider qualifications. CMS guidance CMS-2237-IFC (7) states "When a target group consists solely of individuals with developmental disabilities or chronic mental illness, States my limit provider participation to specific persons or entities by setting forth qualifying criteria that assure the ability of the case managers to connect individuals with needed services". To allow for consistent monitoring of required staff qualifications, certification for the provider is reviewed every three years if provider is not accredited. If provider is accredited criteria is reviewed every 3 or 4 years depending on accrediting body standards. MO HealthNet TCM provider manual is reviewed and updated yearly.

(HCH) Published research-CATIE study that references that individuals with serious mental illness die 25 years younger than the general population due to preventable chronic diseases. DBH also utilizes population health data to determine target areas of treatment. DMH utilizes the data submitted to DBH from HCH providers to help providers focus their treatment. Criteria was developed by DBH along with stakeholders, including the Coalition of Behavioral Health Centers and providers. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Appeal: (All) DMH Exceptions Committee hears requests for waiver to a rule regarding staff qualifications for services.

State Compliance Determination

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NQTL: Exclusions for Specific Types of Providers Health Plan/State: UnitedHealthCare / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers UnitedHealthCare : Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

UnitedHealthCare : N/A FFS: N/A

Compliance Analysis UnitedHealthCare : Follows FFS policy regarding exclusion of licensed marital and family therapists from enrolling / network admission.

FFS: Licensed marital and family therapists are not enrolled as providers. Licensed clinical social workers may provide services to children in any setting, but services to adults are limited to FQHC, RHC, CMHC settings. Licensed professional counselors may provide services to children in any setting, but services to adults are limited to CCBHC. State Compliance Determination Complies Follow up Doesn’t Comply Action: MHD is amending state plan to add these providers.

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NQTL: Exclusions for Specific Types of Providers Health Plan/State: Missouri Care / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care : Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Missouri Care : N/A FFS: N/A

Compliance Analysis Missouri Care: Follows FFS policy regarding exclusion of licensed marital and family therapists from enrolling / network admission.

FFS: Licensed marital and family therapists are not enrolled as providers. Licensed clinical social workers may provide services to children in any setting, but services to adults are limited to FQHC, RHC, CMHC settings. Licensed professional counselors may provide services to children in any setting, but services to adults are limited to CCBHC.

State Compliance Determination Complies Follow up Doesn’t Comply Action: MHD is amending state plan to add these providers

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NQTL: Provider Reimbursement / Usual, Customary, and Reasonable Determination Health Plan/State: Home State Health / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Home State Health: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Home State Health: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Compliance Analysis Home State: For both MH/SUD and M/S, provider agreements are based on state Medicaid or federal (Medicare) published fee schedules. The vast majority are paid 100% of the published rates and are updated based on published changes from the state. The state or federal billing codes are reviewed on a routine basis to ensure that all services are being adjudicated properly. Review state Medicaid/Medicare rates for approved services, offer these rates at 100% of schedule. We do not use U&C rates for Medicaid/Medicare providers, we pay non-par providers 100% of the state rate or the non-par state fee schedule. If provider does not accept 100% of state rates; then we follow the below. Research: 1. Review location do we already have existing providers in this location, services – do they have services not found in another area? 2. Are they specific to a certain demographic, ie: age, programming, etc. 3. Network need – is this provider filling a network gap? 4. How much membership would the provider access? If, yes to 1-3 proceed to next steps Claims/UM Review

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1. Review claim utilization for existing codes 2. Speak to clinical team regarding any quality issues and discuss network need if applicable 3. Research to quality for any reported concerns Proposal 1. Create table of scenarios with adjusted rates in X% increments of published guardrails 2. Review guardrails from adjacent states 3. If all items are favorable, if higher than 3% of guardrails, send to VP of Network for prior approval before sending to provider

Triggers to adjust provider fee schedules are based on requests from providers, or review of claims data and the same steps as above The state Medicaid or Medicare rates are the baseline for reimbursements. Other factors may be considering such as network need, specialized services and provider types. Increases are based on state Medicaid or Medicare rates. With the exception of emergency room services, all non-participating providers and services require prior authorization. If the provider does not obtain authorization, the claims will be denied. Non-par providers will be paid the state Medicaid or Medicare unless they request a single case agreement. If one is requested an agreement will be signed for that specific case. Network adequacy is evaluated each quarter by formal reporting utilizing an analytics tool that generates coverage maps. Deficiencies would be shown and addressed. Based on any inadequacy by specialty or by county, the behavioral health vendor along with HSH would explore which area providers are not participating and the history of any negotiations. Emails received from providers as well as health plan responses are stored. FFS: The MO HealthNet Division is charged with establishing and administering the rate of payment for those medical services covered by the Missouri Title XIX Program. The Division establishes a rate of payment that meets the following goals:  Ensures access to quality medical care for all participants by encouraging a sufficient number of providers;  Allows for no adverse impact on private-pay patients;  Assures a reasonable rate to protect the interests of the taxpayers; and  Provides incentives that encourage efficiency on the part of medical providers. Funds used to reimburse providers for services rendered to eligible participants are received in part from federal funds and supplemented by state funds to cover the costs. The amount of funding by the federal government is based on a percentage of the allowable expenditures. The

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percentage varies from program to program and in some cases different percentages for some services within the same program may apply. Funding from the federal government may be as little as 60% or as much as 90%; depending on the service and/or program. The balance of the allowable, (10-40%) is paid from state General Revenue appropriated funds. Total expenditures for MO HealthNet must be within the appropriation limits established by the General Assembly. If the expenditures do not stay within the appropriation limits set by the General Assembly and funds are insufficient to pay the full amount, then the payment for services may be reduced pro rata in proportion to the efficiency. Reimbursement for Behavioral Health services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by the State Agency to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider's actual billed charge (should be the provider's usual and customary charge to the general public for the service), or the maximum allowable per unit of service. Under a fee system each procedure, service, medical supply and equipment covered under a specific program has a maximum allowable fee established. In determining what this fee should be, the MO HealthNet Division uses the following guidelines:  Recommendations from the State Medical Consultant and/or the provider subcommittee of the Medical Advisory Committee;  Medicare’s allowable reasonable and customary charge payment or cost-related payment, if applicable;  Charge information obtained from providers in different areas of the state. Charges refer to the usual and customary fees for various services that are charged to the general public. Implicit in the use of charges as the basis for fees is the objective that charges for services be related to the cost of providing the services. The MO HealthNet Division then determines a maximum allowable fee for the service based upon the recommendations, charge information reviewed and current appropriated funds.

State Compliance Determination Complies Follow up Doesn’t Comply

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NQTL: Provider Reimbursement / Usual, Customary, and Reasonable Determination Health Plan/State: Missouri Care Health / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care Health: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Missouri Care Health: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Compliance Analysis Missouri Care: For both MH/SUD and M/S, WellCare utilizes the fee schedules prescribed by the State for reimbursing providers. All providers are reimbursed at 100% of the State’s fee schedule unless there is a geographic or provider availability issue that requires a higher percentage of the State’s fee schedule. None of the following factors affect how reimbursement rates are determined: • Service Type • Geographic Market • Service demand • Provider Supply • Practice Size • Medicare reimbursement rates • Licensure

*WellCare utilizes the fee schedule prescribed by the State for reimbursing providers as noted above. All providers are reimbursed at 100%

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of the State’s fee schedule unless there is a geographic or provider availability issue that requires a higher percentage of the State’s fee schedule. Missouri Care utilizes the States Medicaid Fee Schedule for establishing rates statewide. Inpatient and outpatient reimbursement rates are based on the state’s annually published rates which are calculated utilizing the providers annual cost report. In the event there is a need to deviate from this standard; a market feasible rate is negotiated through collaborative negotiations to elicit the greatest value. Exceptions are approved by the VP of Field Network Management and the Plan President. Missouri Care reimburses out of network providers at 100% of the current Missouri Medicaid rate and payment methodology. FFS: The MO HealthNet Division is charged with establishing and administering the rate of payment for those medical services covered by the Missouri Title XIX Program. The Division establishes a rate of payment that meets the following goals:  Ensures access to quality medical care for all participants by encouraging a sufficient number of providers;  Allows for no adverse impact on private-pay patients;  Assures a reasonable rate to protect the interests of the taxpayers; and  Provides incentives that encourage efficiency on the part of medical providers. Funds used to reimburse providers for services rendered to eligible participants are received in part from federal funds and supplemented by state funds to cover the costs. The amount of funding by the federal government is based on a percentage of the allowable expenditures. The percentage varies from program to program and in some cases different percentages for some services within the same program may apply. Funding from the federal government may be as little as 60% or as much as 90%; depending on the service and/or program. The balance of the allowable, (10-40%) is paid from state General Revenue appropriated funds. Total expenditures for MO HealthNet must be within the appropriation limits established by the General Assembly. If the expenditures do not stay within the appropriation limits set by the General Assembly and funds are insufficient to pay the full amount, then the payment for services may be reduced pro rata in proportion to the efficiency. Reimbursement for Behavioral Health services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by the State Agency to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider's actual billed charge (should be the provider's usual and customary charge to the general public for the service), or the maximum allowable per unit of service. Under a fee system each procedure, service, medical supply and equipment covered under a specific program has a maximum allowable fee established. In determining what this fee should be, the MO HealthNet Division uses the following guidelines:  Recommendations from the State Medical Consultant and/or the provider subcommittee of the Medical Advisory Committee;

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 Medicare’s allowable reasonable and customary charge payment or cost-related payment, if applicable;  Charge information obtained from providers in different areas of the state. Charges refer to the usual and customary fees for various services that are charged to the general public. Implicit in the use of charges as the basis for fees is the objective that charges for services be related to the cost of providing the services. The MO HealthNet Division then determines a maximum allowable fee for the service based upon the recommendations, charge information reviewed and current appropriated funds. State Compliance Determination Complies Follow up Doesn’t Comply

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NQTL: Provider Reimbursement / Usual, Customary, and Reasonable Determination Health Plan/State: UnitedHealthcare Health / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers UnitedHealthcare Health: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

UnitedHealthcare Health: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Compliance Analysis UnitedHealthcare:

Reimbursement is based on the providers’ contracts. In general UnitedHealthcare uses the current MHD fee schedules and payment methodology as the basis for inpatient, outpatient, and emergency care contracting. Incentives may be used in addition in order to improve the robustness of the provider network in areas of need.

Reimbursement is also based on application of NCCN edits, CMS edits, and internal proprietary policies applied to reduce duplication and abuse of standard CPT and HCPCS codes.

Steps: 1. Review most current fee schedule/rates from MO Medicaid website 2. Local C&S Finance approve rates if above 100% of MO Medicaid

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3. All pricing is based upon MO Medicaid fee schedules 4. Any request for increases to a providers Medicaid fee schedule is directed to Network Management. If the request is made during an open negotiation, NM works with C&S Finance to assess the viability of the requested rates. NM will then negotiate the rates as appropriate with the provider. 5. Rates are reassessed after the initial term of the agreement ends with the provider United uses the current MHD fee schedules and payment methodologies in order to reduce provider abrasion and improve contracting consistency. The final methodology applied to each provider will depend on the details of any negotiated contract. Contracts and fee schedules may be adjusted to establish appropriate provider networks and to address issues such service type, geographic market, demand for services, supply, practice size, provider qualifications, etc. United uses the Medicaid fee schedule as the basis for provider contracts in order to most closely mimic the current state methodology for establishing medical cost expectations. FFS: The MO HealthNet Division is charged with establishing and administering the rate of payment for those medical services covered by the Missouri Title XIX Program. The Division establishes a rate of payment that meets the following goals:  Ensures access to quality medical care for all participants by encouraging a sufficient number of providers;  Allows for no adverse impact on private-pay patients;  Assures a reasonable rate to protect the interests of the taxpayers; and  Provides incentives that encourage efficiency on the part of medical providers. Funds used to reimburse providers for services rendered to eligible participants are received in part from federal funds and supplemented by state funds to cover the costs. The amount of funding by the federal government is based on a percentage of the allowable expenditures. The percentage varies from program to program and in some cases different percentages for some services within the same program may apply. Funding from the federal government may be as little as 60% or as much as 90%; depending on the service and/or program. The balance of the allowable, (10-40%) is paid from state General Revenue appropriated funds. Total expenditures for MO HealthNet must be within the appropriation limits established by the General Assembly. If the expenditures do not stay within the appropriation limits set by the General Assembly and funds are insufficient to pay the full amount, then the payment for services may be reduced pro rata in proportion to the efficiency. Reimbursement for Behavioral Health services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by the State Agency to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for

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covered services is the lower of the provider's actual billed charge (should be the provider's usual and customary charge to the general public for the service), or the maximum allowable per unit of service. Under a fee system each procedure, service, medical supply and equipment covered under a specific program has a maximum allowable fee established. In determining what this fee should be, the MO HealthNet Division uses the following guidelines:  Recommendations from the State Medical Consultant and/or the provider subcommittee of the Medical Advisory Committee;  Medicare’s allowable reasonable and customary charge payment or cost-related payment, if applicable;  Charge information obtained from providers in different areas of the state. Charges refer to the usual and customary fees for various services that are charged to the general public. Implicit in the use of charges as the basis for fees is the objective that charges for services be related to the cost of providing the services. The MO HealthNet Division then determines a maximum allowable fee for the service based upon the recommendations, charge information reviewed and current appropriated funds.

State Compliance Determination Complies Follow up Doesn’t Comply

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NQTL: Geographic Restrictions / Travel Time and Distance Requirements / Standards for Out of Network Coverage Health Plan/State: Home State Health / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Home State Health: Covered Inpatient and Outpatient Services FFS: CPR and Covered Inpatient and Outpatient Services for COA 4

Home State Health: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Compliance Analysis Home State: HSH has a comprehensive network of contracted IP and OP providers and makes every effort to manage care within the contracted network. However, HSH will authorize services to non-participating providers as needed to ensure timely access to quality care if there are no appropriate contracted providers, if a member requires services when outside the service area or to ensure transition and continuity of care. Authorization for non-participating providers is managed by HSH's Medical Management team including concurrent review, utilization management and medical directors. Once the authorization is approved, Medical Management notifies the Network Management Department and a Single Case Agreement is executed to document the agreed upon services and reimbursement. This document is signed by both the provider(s) and HSH and a copy returned to the provider and placed in HSH file.

If an in-network provider who is qualified and able to provide the service is not available the following occurs: The UM designee will send the request for Medical Director Review with the following documentation. i. Reason for requesting an out-of-network provider

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ii. Name and specialty of the out-of-network provider iii. Results of the in-network search v. Medical necessity review, if required vi. Any additional information

Upon evaluation of the Medical Director outcome. i. UM designee will follow approval and/or denial process per plan policies (UM.05 – Timeliness of UM Decisions and Notifications and UM.07 – Adverse Determination (Denial) Notices)

If an out-of-network provider is approved: i. Authorization is entered into the Clinical Documentation System and notice is provided as defined in UM.05. o The provider will be notified of how to access information related to plan billing and payment (ex. plan website, provider manuals, state fee schedule, etc.). o If the provider states they are not willing to accept the applicable fee schedule, the provider will be notified that a Single Case Agreement (SCA) is required and if rates can’t be agreed upon, the authorization may be denied and another provider may be found to serve the member.

Special considerations a. Out-of-network Inpatient Admissions and/or Urgent Requests. i. Out-of-network inpatient admissions may occur as a result of an emergency urgent situation. The Plan will evaluate the unique circumstances surrounding the health care needs of the member. ii. Authorization is not required for emergent/urgent care. -Once the member becomes stable, Care Management (CM) will assist in transitioning the member to an in-network facility/provider. -If the member is unable to be transitioned in-network, the Plan continues to monitor the member’s condition and authorizes services as appropriate.

b. Out-of-network requests are considered when a participating provider is only affiliated with an out-of-network facility and may require Advisor Review (follow Health Plan policy). c. Out-of-network providers are considered for second opinion requests based on member contract, and may require Advisor Review (follow Health Plan policy). d. Inpatient or outpatient “out of area services” will be considered for treatment of unexpected illness or injury. Advisor Review may be

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required for approval (per Health Plan policy). i. A CM will assist in transition to an in-network provider as appropriate.

With the exception of emergency room services, all non-participating providers and services require prior authorization. If the provider does not obtain authorization, the claims will be denied. Non-par providers wil be paid the state Medicaid or Medicare unless they request a single case agreement. If one is requested an agreement will be signed for that specific case. MH/SUD standards for out-of-network coverage are applied in accordance with MO HealthNet Managed Care contractual requirements in order to ensure that enrollees have access to medically necessary services and to ensure a smooth transfer of care from nonparticipating to participating providers, as needed. MH/SUD provider network adequacy is regularly assessed against MO HealthNet Managed Care contractual standards in order to identify potential care access gaps and determine where an enrollee's best interest can be served by out-of- network coverage. Network adequacy is reviewed on an ongoing basis to assess members' access to care across the state. Our database and website are updated on a daily basis to ensure current information regarding in-network and out-of-network providers is available to all HSH employees and our members. This policy applies to all non-participating providers with the exception of emergency services. The Single Case Agreement policy is reviewed at least annually and may be revised to accommodate needed changes at any time.

FFS (applies for COA 4 members): All non-emergency, MO HealthNet-covered services that are to be performed or furnished out of state for eligible MO HealthNet participants and for which MO HealthNet is to be billed, must be prior authorized before the services are provided. Services that are not covered by the MO HealthNet Program are not approved. Out of state is defined as not within the physical boundaries of the state of Missouri or within the boundaries of any state that physically borders on the Missouri boundaries. Border-state providers of services (those providers located in Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma and Tennessee) are considered as being on the same MO HealthNet participation basis as providers of services located within the state of Missouri. A PA Request form is not required for out-of-state non- emergency services. To obtain prior authorization for out-of-state, non-emergency services, a written request must be submitted (and may be faxed). The written request must include: 1. A brief past medical history; 2. Services attempted in Missouri; 3. Where the services are being requested and who will provide them; and 4. Why services can’t be performed in Missouri.

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NOTE: The out-of-state medical provider must agree to complete an enrollment application and accept MO HealthNet reimbursement. Prior authorization for out-of-state services expires 180 days from the date the specific service was approved by the state. The following are exempt from the out-of-state prior authorization requirement: 1. All Medicare/MO HealthNet crossover claims; 2. All foster care children living outside the state of Missouri. However, non-emergency services that routinely require prior authorization continue to require prior authorization by out-of-state providers even though the service was provided to a foster care child; 3. Emergency ambulance services; and 4. Independent laboratory services.

CPR – Although 9 CSR 30-4.039 specifies 1 ½ hours of travel time is reasonable to ensure access, services may be provided in member’s home or community via telehealth. DBH reviews and responds to inquiries related to travel time.

State Compliance Determination Complies Follow up Doesn’t Comply

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NQTL: Geographic Restrictions / Travel Time and Distance Requirements / Standards for Out of Network Coverage Health Plan/State: Missouri Care Health / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers Missouri Care Health: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Missouri Care Health: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Compliance Analysis Missouri Care:

The only geographic limitations on provider inclusion are the service area of the plan (i.e., the provider must practice within the state where the Medicaid plan is). C7CR-009 For both MH/SUD and M/S, Missouri Care does contract with bordering states. Although Missouri Care does not typically contract with out of state (non-bordering) providers, Missouri Care will enter into a Single Case Agreement upon specific clinical need for MH/SUD or M/S service out of state. The Medicaid plan is an HMO product, thus the member is restricted to their network providers for non-emergent, routine care. Out-of- Network coverage is available for emergency services. The State’s benefit plan design dictates how members can access out of network benefits. If Missouri Care’s network is unable to provide necessary services covered under the contract to a particular member, it is the policy of Missouri Care to adequately and timely cover these services out of network for the member, for as long as Missouri Care is unable to provide them. Missouri Care will ensure that no member residing in the service area must travel an unreasonable distance to obtain covered services. The out of network providers will coordinate with Missouri Care with respect to payment and ensure that the cost to the member is no greater

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than it would be if the services were furnished within the network. Once the Missouri Care clinical team identifies a need for an out of network provider, Missouri Care’s network team will outreach and negotiate a Single Case Agreement. FFS (applies for COA 4 members): All non-emergency, MO HealthNet-covered services that are to be performed or furnished out of state for eligible MO HealthNet participants and for which MO HealthNet is to be billed, must be prior authorized before the services are provided. Services that are not covered by the MO HealthNet Program are not approved. Out of state is defined as not within the physical boundaries of the state of Missouri or within the boundaries of any state that physically borders on the Missouri boundaries. Border-state providers of services (those providers located in Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma and Tennessee) are considered as being on the same MO HealthNet participation basis as providers of services located within the state of Missouri. A PA Request form is not required for out-of-state non- emergency services. To obtain prior authorization for out-of-state, non-emergency services, a written request must be submitted (and may be faxed). The written request must include: 1. A brief past medical history; 2. Services attempted in Missouri; 3. Where the services are being requested and who will provide them; and 4. Why services can’t be performed in Missouri. NOTE: The out-of-state medical provider must agree to complete an enrollment application and accept MO HealthNet reimbursement. Prior authorization for out-of-state services expires 180 days from the date the specific service was approved by the state. The following are exempt from the out-of-state prior authorization requirement: 1. All Medicare/MO HealthNet crossover claims; 2. All foster care children living outside the state of Missouri. However, non-emergency services that routinely require prior authorization continue to require prior authorization by out-of-state providers even though the service was provided to a foster care child; 3. Emergency ambulance services; and 4. Independent laboratory services. CPR – Although 9 CSR 30-4.039 specifies 1 ½ hours of travel time is reasonable to ensure access, services may be provided in member’s home or community via telehealth. DBH reviews and responds to inquiries related to travel time. State Compliance Determination Complies Follow up Doesn’t Comply

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☒ ☐ ☐ NQTL: Geographic Restrictions / Travel Time and Distance Requirements / Standards for Out of Network Coverage Health Plan/State: UnitedHealthcare / FFS Benefit Package(s): Adults (Ages 21+), Pregnant Women (Ages 21+), Children: COA 1, PW (0-20), CHIP Exp., CHIP Separate, COA 4: foster children (ages 0-25), adoption subsidy, DYS, juvenile court Classification: Inpatient and Outpatient MH/SUD Benefits/Providers M/S Benefits/Providers UnitedHealthcare: Covered Inpatient and Outpatient Services FFS: CPR and Covered Inpatient and Outpatient Services for COA 4

UnitedHealthcare: Covered Inpatient and Outpatient Services FFS: Covered Inpatient and Outpatient Services

Compliance Analysis UnitedHealthcare: For both MH/SUD and M/S services, individuals accessing benefits are expected to seek treatment from network professionals and facilities within the state or contiguous states When a service is clearly not available from a network provider, arrangements may be made for an out of network provider who otherwise meets United standards of care, including having or being willing to obtain an Missouri Medicaid provider ID.

Services not meeting the criteria of emergent/Acute are not covered out of network. Emergent and unplanned admissions are reimbursed based on the fee schedule when appropriate or through a single case agreement. UHC does contract with providers in bordering states. Process: M/S will contract under a single case agreement (SCA) when services are rendered to a MO member in another state. The out-of- state provider must call the HP for authorization to treat. The intake nurses will inquire of the provider if they are willing to provide the services at 100% of the Missouri Medicaid rate. If the provider accepts, then a note is entered by the intake nurse into the system so the claim can be paid. A SCA is not necessary under these circumstances. If the out-of-state provider will not accept 100% of Missouri Medicaid, then a SCA form is sent to Network Management. Once the SCA form is received, the appropriate contractor is assigned to the SCA. This person will, in turn, negotiate a rate with the provider. Once this is complete, the SCA is entered into the system so the claim will be properly

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adjudicated. All benefits are subject to this NQTL. The plan allows for access to emergent care outside of the state including unplanned IP admissions and emergent Outpatient care.

UnitedHealthcare contracts with all providers as designated in the state Provider Agreement. In addition in areas along our border states we attempt to contract with facilities that are able to service Missouri Medicaid members. Services not meeting the criteria of emergent/Acute are not covered out of network. Emergent and unplanned admissions are reimbursed based on established UCR process (fee schedule INN, accommodation OON). UHC follows geographic standards specified by the state for both MH/SUD and M/S services. FFS (applies for COA 4 members): All non-emergency, MO HealthNet-covered services that are to be performed or furnished out of state for eligible MO HealthNet participants and for which MO HealthNet is to be billed, must be prior authorized before the services are provided. Services that are not covered by the MO HealthNet Program are not approved. Out of state is defined as not within the physical boundaries of the state of Missouri or within the boundaries of any state that physically borders on the Missouri boundaries. Border-state providers of services (those providers located in Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma and Tennessee) are considered as being on the same MO HealthNet participation basis as providers of services located within the state of Missouri. A PA Request form is not required for out-of-state non- emergency services. To obtain prior authorization for out-of-state, non-emergency services, a written request must be submitted (and may be faxed). The written request must include: 1. A brief past medical history; 2. Services attempted in Missouri; 3. Where the services are being requested and who will provide them; and 4. Why services can’t be performed in Missouri. NOTE: The out-of-state medical provider must agree to complete an enrollment application and accept MO HealthNet reimbursement. Prior authorization for out-of-state services expires 180 days from the date the specific service was approved by the state. The following are exempt from the out-of-state prior authorization requirement: 1. All Medicare/MO HealthNet crossover claims; 2. All foster care children living outside the state of Missouri. However, non-emergency services that routinely require prior authorization continue to require prior authorization by out-of-state providers even though the service was provided to a foster care child; 3. Emergency ambulance services; and 4. Independent laboratory services.

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CPR – Although 9 CSR 30-4.039 specifies 1 ½ hours of travel time is reasonable to ensure access, services may be provided in member’s home or community via telehealth. DBH reviews and responds to inquiries related to travel time.

State Compliance Determination Complies Follow up Doesn’t Comply

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NQTL: Drugs Not Covered Pursuant to Section 1927(d)(2) Health Plan/State: State Benefit Package(s): All Classification: Prescription Drugs MH/SUD Benefits/Providers M/S Benefits/Providers Certain MH/SUD prescription drugs

Certain M/S prescription drugs Compliance Analysis MO HealthNet covers certain drugs specified in section 1927(d)(2) of the Social Security Act and excludes others. The excluded categories and MO HealthNet’s exceptions noted in parentheses are listed below: A. Agents when used for weight loss. B. Agents when used to promote fertility. (MO HealthNet covers Aromatase inhibitors for cancer and cancer drugs are not edited) C. Agents when used for cosmetic purposes or hair growth. D. Agents when used for the symptomatic relief of cough and colds. (MO HealthNet has a covered Cough & Cold list) http://dss.mo.gov/mhd/cs/pharmacy/pdf/cough_cold.pdf E. Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations. F. Nonprescription drugs, except, in the case of pregnant women when recommended in accordance with the Guideline referred to in section 1905(bb)(2)(A), agents approved by the Food and Drug Administration under the over-the-counter (OTC) monograph process for purposes of promoting, and when used to promote, tobacco cessation. (MO HealthNet has a covered list of OTC products) http://dss.mo.gov/mhd/cs/pharmacy/pdf/otc_coveredproducts.pdf G. Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee. H. Barbiturates. (MO HealthNet covered in accordance with 1927(d)(7)) I. Benzodiazepines. (MO HealthNet covered in accordance with 1927(d)(7)) J. Agents when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile

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dysfunction, for which the agents have been approved by the Food and Drug Administration. Certain drugs may have both medically-necessary indications and lifestyle indications. In these cases, in order to verify medical necessity, prior authorization is required (see Prior Authorization NQTL analysis below).

Section 1927(d)(2) of the Social Security Act allows the exclusion of certain drugs that may not always be medically necessary, generally considered “lifestyle drugs” (used to improve quality of life rather than for alleviating pain or managing or curing an illness). These include agents for weight loss, to promote fertility, for cosmetic purposes and to treat sexual or erectile dysfunction. MO HealthNet’s decision to exclude these drugs is not based on whether the drugs are used for a MH/SUD condition or a M/S condition; the processes, strategies, and evidentiary standards appear to be the same for both MH/SUD and M/S medications.

State Compliance Determination Complies ☑

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NQTL: Requiring Use of Preferred Drugs Before Approving Non-Preferred Agents (Step Therapy) Health Plan/State: State Benefit Package(s): All Classification: Prescription Drugs MH/SUD Benefits/Providers M/S Benefits/Providers Certain MH/SUD prescription drugs Certain M/S prescription drugs Compliance Analysis MO HealthNet’s preferred drug list (PDL) requires members to try and fail preferred agents prior to receiving non-preferred agents, a common practice known as Step Therapy (ST). If a member is prescribed a non-preferred agent prior to trying the preferred agent(s), a claim for a non-preferred agent will be denied. Once preferred agents are filled, the tried and failed medications are documented in a member’s claims history. The past claims records will serve to fulfill ST in the payer system and allow the non-preferred agent to be filled without further intervention. If the preferred agent is not prescribed to the member because the physician believes it is not the appropriate therapy for a given member, the physician may use the prior authorization process to seek an exception to the ST requirement. Members are required to try and fail preferred agents prior to receiving non-preferred agents to encourage the use of cost-effective drug therapies (preferred agents) prior to being able to fill the more expensive drug therapies (non-preferred agents). Preferred agents are more cost-effective than non-preferred agents. Preferred agents typically account for nearly 80% of a program’s total prescription fills, but only 20%-30% of the cost. A recent Blue Cross/Blue Shield study using pharmacy data from years 2010 through 2016 reinforced this general split between preferred drugs (primarily generics) and non-preferred; the study can be accessed here: https://www.bcbs.com/sites/default/files/file-attachments/health-of-america-report/BCBS.HealthOfAmericaReport.RisingCostsPatentedDrugs_1.pdf ST requirements are primarily based on a medication’s cost and generic/brand status. Thus, the strategies, processes and evidentiary standards appear to be comparable and of the same stringency, regardless of whether the medications are for treatment of MH/SUD or M/S conditions or both. State Compliance Determination Complies ☑

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NQTL: Prior Authorization Health Plan/State: State Benefit Package(s):All Classification: Prescription Drugs MH/SUD Benefits/Providers M/S Benefits/Providers Certain MH/SUD prescription drugs

Certain M/S prescription drugs

Compliance Analysis MO HealthNet’s PDL covers some medications only with advance approval from MO HealthNet, a common practice known as prior authorization. To obtain prior authorization for a drug, the prescriber may either call the request in to the prior authorization phone line or fax a completed request form to MO HealthNet.

Requests for prior authorization will be evaluated and MO HealthNet will provide a response by telephone or other telecommunication device within 24 hours. If required, a 72-hour supply of a covered outpatient drug can be dispensed in an emergency situation, except with respect to the drugs on the list of drugs permissible for exclusion.

MO HealthNet has two groups involved in developing prior authorization requirements, the MO HealthNet Drug Prior Authorization Committee and the Drug Use Review (DUR) Board. The MO HealthNet Drug Prior Authorization Committee consists of three practicing pharmacists, three physicians and one registered nurse. The DUR Board consists of clinicians appointed by the governor and confirmed by the senate. A quorum of two-thirds (2/3) of the total members, including no fewer than two (2) physicians or two (2) pharmacists, is required for the DUR Board to act in its official capacity.

The MO HealthNet Drug Prior Authorization Committee reviews medications, prescribing guidelines and accepted clinical practice to recommend medications for prior authorization. The DUR Board reviews and approves or rejects the recommendations.

Circumstances leading the Drug Prior Authorization Committee and DUR board to recommend the requirement of prior authorization include, but are not limited to, the following:

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Medical necessity is not clearly evident. Potential for diversion, misuse and abuse. High cost of care relative to similar therapies. Opportunity for unlabeled use defined as the use of a drug product in doses, patient populations, indications or routes of administration that are not reflected in the FDA approved product labeling. Medications may be limited to the maximum FDA approved dose. Medications may be limited to the minimum FDA approved age limitations. Drug classes where there is an identified potential for not keeping within the MO HealthNet policy guidelines. New drugs that come to market that are in one of the therapeutic categories covered by the PDL. Certain drugs, for example those in Social Security Act section 1927(d)(2), may have both medically-necessary indications and lifestyle indications. In these cases, in order to verify medical necessity, prior authorization is required. Pain medications, such as opioids, have a high street value and are prone to addiction and misuse. One recent case involving 12 U.S. attorneys’ offices resulted in $150 million in DEA civil penalties against McKesson Corp., a distributor of pharmaceuticals, to address its failure to report suspicious opioid orders. Prior authorization for drugs with this potential helps to manage and monitor the quantity being dispensed. As addressed above in ST, cost-effective treatments are preferred over more expensive equivalent treatments. To gain exception to trying and failing the cost- effective option, prior authorization may be used. Opportunity exists for unlabeled use defined as the use of a drug product in doses, patient populations, indications or routes of administration that are not reflected in the FDA approved product labeling. PAs are used for the purpose of containing costs and to ensure the proper utilization of drug therapies. The Drug Prior Authorization Committee recommends PAs based on FDA prescribing guidelines and accepted clinical practice. All recommendations must be reviewed and approved by the DUR Board prior to implementation. The strategies, processes and evidentiary standards appear to be comparable and of the same stringency, regardless of whether the medications are for treatment of MH/SUD or M/S conditions or both.

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State Compliance Determination Complies ☑

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NQTL: Early Refills Health Plan/State: State Benefit Package(s): All Classification: Prescription Drugs MH/SUD Benefits/Providers M/S Benefits/Providers All MH/SUD prescription drugs

. All M/S prescription drugs

Compliance Analysis Prescription refills for MO HealthNet members are not allowed until 75% of the previous fill has been used (85% for opioids). If the prescriber has changed the directions for a member’s medication requiring an early refill, the pharmacy may call Pharmacy Services with the new dosing details to gain an approval.

Early refill edits help to prevent stockpiling and abuse. Exceptions to the early refill restriction can be approved through the prior authorization process when necessary, for example if medication has been lost or stolen, or if a member is planning for extended travel.

MO HealthNet’s early refill edits are applied uniformly across all drug categories, with the exception of opioids, which have a higher threshold due to their abuse and addiction potential. The strategies, processes and evidentiary standards appear to be comparable and of the same stringency, regardless of whether the medications are for treatment of MH/SUD or M/S conditions or both. State Compliance Determination Complies ☑

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NQTL: Shared Pharmacy Dispensing Fees (Copays) Health Plan/State: State Benefit Package(s):All Classification: Prescription Drugs MH/SUD Benefits/Providers M/S Benefits/Providers All MH/SUD prescription drugs

All M/S prescription drugs

Compliance Analysis Shared dispensing fees are assessed by MO HealthNet when the claim is submitted by the pharmacy. The pharmacist is responsible for assessing the shared dispensing fees at point of sale when dispensing the medication to the member. Shared dispensing fees are assessed to share health care costs between payers and members, and to avoid members seeking unneeded services. In order to share the cost proportionately, the State set shared dispensing fees by tier to charge lower shared dispensing fees for less expensive drugs and higher shared dispensing fees for more expensive drugs. MO HealthNet’s shared dispensing fees are tiered as follows: Drug ingredient cost between $0–$10.00 = $0.50 shared dispensing fee Drug ingredient cost between $10.01–$25.00 = $1.00 shared dispensing fee Drug ingredient cost higher than $25.00 = $2.00 shared dispensing fee o

o All members are assessed the shared dispensing fees, with the exception of the following which are excluded: Services to participants under age 19; Services to institutionalized participants who are residing in a skilled nursing facility, intermediate care facility, adult boarding home, psychiatric hospital or FFS participants in a residential care facility; Services to foster care children under 26 years of age;

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Services to all Medicare/MO HealthNet participants with crossover claims as primary coverage; Those drugs specifically identified as relating to family planning services; Emergency services in an outpatient clinic or emergency room; Services provided to pregnant women which are directly related to the pregnancy or a complication of the pregnancy; Services provided to persons receiving MO HealthNet under the categories of Aid to the Blind; and Services which are prescribed and identified as relating to an Early Periodic Screening, Diagnosis and Treatment Program screening or referral service. o o Shared dispensing fees are assessed to share health care costs between payers and members, and to avoid members seeking unneeded services. The copays are based on the overall cost of the medication, and thus, are applied with the same comparability and stringency regardless of whether the drug is for MH/SUD or M/S conditions. State Compliance Determination Complies ☑

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NQTL: Reimbursement for prescription drugs Health Plan/State: State Benefit Package(s):All Classification: Prescription Drugs MH/SUD Benefits/Providers M/S Benefits/Providers All MH/SUD prescription drugs

All M/S prescription drugs

Compliance Analysis MO HealthNet’s reimbursement logic is designed to fairly compensate providers for providing prescription drugs.

The State reimburses pharmacy providers as follows:

Federal Upper Limit (FUL), if no FUL then State SMAC, if no State Maximum Allowable Cost (SMAC) then Wholesale Acquisition Cost (WAC) minus 3.1%.*

FUL is a national benchmark maintained by CMS. In aggregate, CMS requires FFS Medicaid pharmacy programs to reimburse at or below the FUL rate for all drugs with FUL rates available.

WAC is a regularly updated pharmacy industry pricing benchmark. WAC is based on manufacturer-reported prices. Government program payers generally pay at WAC or less for brand drugs, with further discounts on generic drugs achieved through the use of SMAC lists.

These pricing benchmarks help the State responsibly use Medicaid funds while also providing adequate reimbursement to pharmacies to ensure beneficiary access. If a pharmacy is unable to dispense a medication at the SMAC rate and still cover its costs, the pharmacy can appeal to the State for a pricing review and provide evidence of their actual purchase price.

Missouri’s Medicaid reimbursement logic is designed to fairly compensate providers for providing prescription drugs. The MO HealthNet logic is based on industry-standard payment metrics that generally are considered to adequately compensate pharmacy providers for medications.

o The reimbursement logic is based on pricing metrics that are determined by market pricing forces, not by the condition that the medication treats, and thus the

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processes, strategies, and evidentiary standards are applied with the same comparability and stringency regardless of whether the drug is for MH/SUD or M/S conditions. o

*Reimbursement logic in place, but not yet granted final CMS approval State Compliance Determination Complies ☑

_____________________________________________________________________________ Table of Contents State/Territory Name: Missouri State Plan Amendments (SPA) #: MO-19-0014 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-16 Baltirnore, MD 21244-1850 (curs c[NltRs fo{ MtDtcAnE & MtDtcAtD s¡ßvtcts CENIEn ¡Ot lì,tEDtCAtD & CÍtp SEnVtCfS Children and Adults Health Grouo JUL 2 5 2019 Todd Richardson Director MO HealthNet Division State of Missouri, Department of Social Services 615 Howerton Court, PO Box 6500 Jefferson City, MO 65102 Dear Mr. Richardson: Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) MO- 19-0014 has been approved. MO-19-0014 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L for use of a managed care delivery system. This SPA has an effective date of July 1,2018. Sections 2101(a),2103(Ð(3), 2107(b), and2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Missouri has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state's separate child health plan. This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state's CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on July 1, 2018 must comply with the CHIP managed care regulations and be submitted for CMS review. Your title XXI project officer is Ms. Kristin Edwards. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Edwards' contact information is as follows: Centers for Medicare & Medicaid Services Center fbr Medicaid and CHIP Services Mail Stop: 52-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (41 0) 786-5480 E-mail: kristin.edwards(¿Ðcms.hhs. gov

Page 2 - Mr. Todd Richardson Official communications regarding program mattets should be sent simultaneously to Ms. Edwards and to Mr. James Scott, Director, in our Medicaid Field Operations North Division. Mr, Scott's address is: Centers for Medicare & Medicaid Services Division of Medicaid Field Operations North Richard Bolling Federal Building 601 East 12th Street, Room 355 Kansas City, MO 64106-2808 We look forward to continuing to work with you and your staff. Marie Costello Director cc: Mr. James Scott, Director, Division of Medicaid Field Operations North /signed Anne Marie Costello/

Missouri Application for the State Children’s Health Insurance Program

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1.4 Effective Dates

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment. (42 CFR 457.65) Effective date (date State incurs costs): Initial Combination SCHIP State Plan Submission, SPA #3: September 1, 2007 SPA #4: Disapproved December 19, 2008 SPA #5: Effective May 1, 2009 SPA #6: Effective July 1, 2009 SPA #7: Withdrawn June 29, 2011 SPA #8: Effective July 1, 2011 MO-15-0009-CHIP: Effective January 1, 2016 MO-15-0010: Effective January 1, 2016 MO-15-0011: Effective January 1, 2016 MO-17-002: Effective May 1, 2017 MO-18-0015: Effective July 1, 2017 MO-19-0014: Effective July 1, 2018 Implementation date (date services begin): SPA #3: September 1, 2007 SPA #4: Disapproved December 19, 2008 SPA #5: May 1, 2009 SPA #6: July 1, 2009 SPA #7: Withdrawn June 29, 2011 SPA #8: Effective July 1, 2011 MO-15-0009-CHIP: Effective January 1, 2016 MO-15-0010: Effective January 1, 2016 MO-15-0011: Effective January 1, 2016 MO-17-002: Effective May 1, 2017 MO-18-0015: Effective July 1, 2017 MO-19-0014: Effective July 1, 2018

1 Effective Date: July 1, 2018 Approval Date:

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3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee- for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Response: Enrollment in MO HealthNet Managed Care is mandatory statewide for SCHIP 1 and SCHIP 2 eligibles. When SCHIP 1 and SCHIP 2 are newly eligible they receive their services through the Fee-for-Service delivery system until their enrollment with an MCO is effective. SCHIP 1 and SCHIP 2 eligibles may request to opt out of Managed Care if their initial condition changes and they meet the following criteria:

• Are eligible for Supplemental Security Income (SSI) (Title XVI of the Act), • Meet the SSI disability definition as determined by the Department of Social Services, • Are a child with special health care needs (Section 501(a)(1)(D) of the Act),

2 Effective Date: July 1, 2018 Approval Date:

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• Are disabled and 18 or younger (Section 1902 (e)(3) of the Act), • Are receiving foster care or adoption assistance, or • Are in foster care or in out-of-home placement.

If any of these criteria are met, the eligible’s Medicaid eligibility category will change to a non-SCHIP category.

Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

3 Effective Date: July 1, 2018 Approval Date:

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Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. Response: Pharmacy, Comprehensive Substance Abuse Treatment Services, Tobacco Cessation, Applied Behavioral Analysis, School-based Direct Services, and Transplant Services. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment

Response: Missouri pays each MCO a per member per month (PMPM) to cover all services required under the comprehensive benefit package except for carved out services.

Describe population served:

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Response: The PMPM is paid for all SCHIP 1 and SCHIP 2 eligibles enrolled with and MCO.

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line

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Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity).

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• The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2