(spa)(mo-09-10)(approval-document)Missouri Medicaid SPA MO-09-10: Approval Document (approved January 15, 2010, effective October 1, 2009)#
(spa)(mo-09-10)(approval-document)(page-1)Page 1#
DEPARTMENT OF HEALTH & HUMAN SERVICES CII. "S$ Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12
CENTERS for MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21 244-1850
Center for Medicaid and State Operations, CMSO
Ms. Ronald J. Levy, Director
Missouri Department of Social Services JAN 15 a0 P.O. Box 1527
Broadway State Office Building
Jefferson City, Missouri 65102-1527
RE: MO 09-010 Dear Mr. Levy:
We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number (TN) 09-010. Effective for services on or after October 1, 2009, this amendment incorporates Intermediate Care Facilities for persons with Mental Retardation (ICF/MR) certified public expenditure protocol into the Missouri Medicaid State plan. CPEs are used to fund Medicaid services at State-operated ICF/MR habilitation centers.
We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), and 1903(a) of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment 09-010 is approved effective October 1, 2009. We are enclosing the CMS-179 and the amended plan pages.
If you have any questions, please call Tim Weidler at (816) 426-6429. Sincerely, 7a Cindy Mann & Director
Center for Medicaid and State Operations (CMSO)
Enclosures
(spa)(mo-09-10)(attachment)Missouri Medicaid SPA MO-09-10: Attachment (approved January 15, 2010, effective October 1, 2009)#
(spa)(mo-09-10)(attachment)(page-1)Page 1#
ATT. 4-19D Page 228 A
(5)(A)1_ ICF/MR CPE Reimbursement Protocol |. ICF/MR CPE Reimbursement Summary
The Department of Mental Health (DMh), Division of Mental Retardation and Developmental Disabilities (MRDD) operates ICF/MR habilitation centers which are certified to participate in the MO HealthNet program to provide inpatient ICF/MR services and community based waiver services. These two services are combined in the protocol because the funding budget is provided through the ICF/MR habilitation centers. The first service is for MO HealthNet participants who reside in the ICF/MR, discussed below in A. The second service is for Medicaid Waiver homes in the community which some of the habilitation centers operate, discussed below in B.
Consumers served by the ICF/MR habilitation centers are diagnosed with developmental disabilities ranging from mild to severe, with the majority being in the severe/profound range. To be eligible for habilitation center Waiver or ICF/MR services, an, individual must meet MRDD's definition of having a developmental disability as set forth in 630.005 RSMo, and meet MRDD's criteria of requiring placement in an ICF/MR habilitation center.
A. ICF/MR Inpatient Services
The services provided to clients that reside in an ICF/MR habilitation center are known as inpatient services. State-Operated ICE/MRs are reimbursed on a per diem basis for MO HealthNet eligible participants residing in the ICF/MR. The non-federal share of the funding for State-Operated ICF/MR services are from directly appropriated state funds that are included in DMH's budget appropriations. This is much like other MO HealthNet programs where the non-federal share of the funding is from the state general revenue fund that is included in the Department of Social Services (DSS) budget appropriations. The federal share of the payments for the ICF/MR services are made through the DSS, MO HealthNet Division (MHD), consistent with the other MO HealthNet programs, even though the state appropriation for the ICF/MR is made through DMH. .
The State-Operated ICF/MR facilities are reimbursed on a retrospective cost
based reimbursement system with year end settlements. The facilities are paid an interim rate during the fiscal year and after filing a Medicaid cost report for the fiscal year, a retroactive settlement based on allowable cost is determined. If allowable costs exceed the interim payments a settlement of the underpayment amount is paid to the facility. If costs are less than the interim payments, a settlement of the overpayment amount is recouped from the facility. The reimbursement, including the determination of allowable Medicaid cost, is set forth in and made in accordance with the Missouri Medicaid State Plan (State Plan) which has been approved.
State Plan TN # 09-10 Effective Date: __ 10/01/2009 Supersedes TN # _New Page Approval Date: __ JAN 15 2010
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ATT. 4-19D Page 228 B
The reconciliation of CPE and the reimbursement system for State ICF/MR facilities use the same premise of reimbursement being cost based and limited to Medicaid allowable costs. The reimbursement system will not pay a facility more than the Medicaid allowable cost of providing services to the Medicaid recipients it serves.
To comply with CPE procedures, the DMH is responsible for certifying costs eligible for payment, which shall not exceed the maximum allowable under federal rules. Funds for the ICF/MR habilitation centers are included in the final appropriation bill passed by the Missouri General Assembly and signed by the Governor. The state will ensure that the facilities certify these expenditures in accordance with 42 CFR 433.51.
To comply with CPE procedures, the state is responsible for ensuring Medicaid reimbursements do not exceed the ICF/MR's cost of providing Medicaid services. The documentation of costs will be the Medicaid cost reports completed by the DMH on the MHD approved forms and SAMII data. The process for identifying eligible incurred Medicaid costs and ensuring Medicaid payments do not exceed such costs is set forth below.
B. MRDD Medicaid Waiver Services (MRDD Waiver)
Some of the ICF/MR habilitation centers operate MRDD Waiver services that are provided in the community. These services are known as State-Operated independent Supported Living (ISL) arrangements and include residential services, group homes, day habilitation, transportation, etc. They may also serve as transition placement to private Medicaid Waiver providers throughout the State. These State-Operated Waiver settings are staffed by State of Missouri employees and supported by the business office and habilitation staff at the ICF/MR. They are located in nearby communities in residential neighborhoods.
The MRDD Waiver program is reimbursed on a per diem basis for the residential and group home settings, which comprise the majority of the services, and there is a unit rate for the day habilitation and transportation services. The reimbursement rates are established by DMH based on costs, as set forth in State Plan which has been approved.
To comply with CPE procedures, DMH is responsible for certifying costs eligible for payment, which shail not exceed the maximum allowable under federal rules. Funds for the ICF/MR habilitation centers are included in the final appropriation bill passed by the Missouri General Assembly and signed by the Governor. The state will ensure that the facilities certify these expenditures in accordance with 42 CFR 433.51.
State Plan TN # 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approvai Date:
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ATT. 4-19D Page 228 C
To comply with CPE procedures, the state is responsible for ensuring Medicaid reimbursements do not exceed the ICF/MR's cost of providing Medicaid services. Costs associated with the MRDD Waiver program are documented on the ICF/MR cost reports completed by DMH on MHD approved forms and SAMII data. The MRDD Waiver program costs are segregated from allowable |CF/MR costs that are used to determine the inpatient reimbursement. DMH also prepares supplemental schedules, documenting the data specifically related to the MRDD Waiver program. The process for identifying eligible incurred Medicaid costs and ensuring Medicaid payments do not exceed such costs is set forth below.
li. Summary of Missouri Title XIX Cost Report
The MO HealthNet Division (MHD) determines ICF/MR costs from Missouri's Financial and Statistical Report for Nursing Facilities (Title XIX Cost Report), version MSIR-1 (7-93), which all Missouri Medicaid ICF/MRs must submit each year. MHD developed its own Title XIX cost report to collect information from the ICF/MR providers necessary to administer the Missouri Medicaid ICF/MR program and to ensure consistent reporting among ICF/MRs.
The supplemental! pages submitted for the MRDD Waiver program are the same forms and are completed in the same manner as the Title XIX Cost Report, except that only page 1 and Schedule B are completed for the MRDD Waiver program.
Missouri's Title XIX cost report includes several schedules that aid in the analysis and determination of reimbursement of the ICF/MR program. The following explains the ICF/MR data included in the schedules from the Title XIX cost report that MHD will use to perform its reconciliations detailed below in Sections III and IV.
A. Page 1
Details the facility name and provider number, address, facility fiscal year, period of cost report, type of control, accounting basis, number of licensed and Medicaid certified beds, bed days and patient days for reporting period, room reservation days, total and Medicaid occupancy and certification statement attesting to the truth and accuracy of the cost report. :
State Plan TN # 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page - Approval Date: JAN 15. 2010
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ATT. 4-19D Page 228 D
B. Schedule A
Schedule A summarizes the ICF/MR's sources of revenues by line item, which are grouped and subtotaled by major category. The primary groupings of revenues are:
Routine Services;
Ancillary Services;
Other Revenue; and, Deductions from Revenues.
PWN
Schedule A details the revenues associated with the facility's total operations as well as the adjustments and offsets to reflect the revenues only associated with the ICF/MR services, as follows:
4. General Ledger (column 1) - Provides the revenues for the total facility's operations (ie., if the ICF/MR is part of a larger complex that includes a forensic center, waiver program services, etc. the General Ledger column will include the revenues for alli these services).
2. Adjustments (column 2) - Details the adjustments and offsets to revenues for non- covered and/or non-allowable items.
3. Patient Adjusted Revenue (column 3) - Reflects the revenues associated only with ICF/MR services (i.e., if the |CF/MR is part of a larger complex that includes a forensic center, waiver program services, etc. the Patient Adjusted Revenue column will exclude the forensic center, waiver program services, etc. and only reflect the revenues for ICF/MR services).
C. Schedule B
Schedule B summarizes the ICF/MR's expenditures by line item, which are grouped and subtotaled by major category. The primary groupings of expenses are:
Patient Care;
Ancillary Services;
Dietary;
Laundry;
Housekeeping;
Plant Operations;
General and Administrative; and, Other.
ONAAPRWN>
State Plan TN # 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: _ JAN 15 2010
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ATT. 4-19D Page 228 E
Schedule B details the expenses associated with the facility's total operations as well as adjustments and offsets to remove various items so that the expenses reflect only the expenses associated with the ICF/MR services, as follows:
4. General Ledger (column 1) — Details the expenses for the total facility's operations (i.e., if the ICF/MR is part of a larger complex that includes a forensic center, waiver program services, etc., the General Ledger column will include the expenses for all these services).
2. Non-Certified, Non-Related Expenses (column 2) — Details the adjustments to remove expenses not associated with ICF/MR services (i.e., if the ICF/MR is part of a larger complex that includes a forensic center, waiver program services, etc., this column details the adjustment to remove the expenses associated with the forensic center, waiver program services, etc.).
3. Unallowable / Revenue Offsets (column 3) — Details the revenue offsets and adjustments to remove items that are non-allowable or non-covered for Medicaid reimbursement. Any costs pertaining to professional services that are separately reimbursable outside of |CF/MR state plan services are also removed as column 3 adjustments.
4. Patient Related Expenses (column 4) - Reflects the Medicaid allowable expenses associated only with ICF/MR operations. (i.e., if the ICF/MR is part of a larger complex that includes a forensic center, waiver program services, etc., the Patient Related Expenses column will exciude the forensic center, waiver program services, etc. and only reflect the Medicaid allowable expenses for ICF/MR services).
MHD staff audits the cost reports to ensure they are completed in accordance with the ICF/MR regulation. MHD staff follows established audit procedures and verifies that the proper adjustments and offsets have been completed and that costs are reported on the proper lines. The audit staff makes adjustments, offsets and reclassifications to the facility's as filed cost report as necessary to ensure the finalized, audited cost report reflects the Medicaid costs allowable for ICF/MR reimbursement.
State Plan TN # 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: _ JAN 45 2010
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ATT. 4-19D Page 228 F
Ill. Certified Public Expenditures — Determination of Allowable Costs for ICF/MR inpatient Payments and MRDD Waiver Payments
To determine a governmentally-operated ICF/MR's allowable costs and the associated reimbursements when such costs are funded by a State through the certified public expenditure (CPE) process, the following steps must be taken to ensure Federal financial participation:
A. ICF/MR Inpatient Payments and MRDD Waiver Payments
The purpose of the inpatient payments and the MRDD Waiver payments is to provide interim payments that will approximate the costs eligible for Federal financial participation claimed through the CPE process. This computation of establishing interim payments funded by CPEs must be performed on an annual basis and in a manner consistent with the methodology set forth in the approved State Plan.
B. Interim Reconciliation of ICF/MR Inpatient Payments and MRDD Waiver Payments
Each governmentally-operated ICF/MR's interim certifiable expenditures will be reconciled based on the Missouri Title XIX cost report for the spending year in which interim payments were made. The State will adjust, as necessary, the aggregate amount of interim funds claimed based on the total certifiable expenditures determined under the interim reconciliation. If, at the end of the interim reconciliation process, it is determined that funding was over-claimed, the overpayment will be properly credited to the federal government.
The ICF/MR costs will be obtained from the Missouri Title XIX cost report, including the supplemental pages for the MRDD Waiver costs, which has been completed by DMH and submitted to MHD (i.e., as-filed cost report). The data shall be obtained from the facility's as-filed Missouri Title XIX cost report for the fiscal year being reconciled. For example, a facility's payments received for SFY 2009 will be reconciled to the costs from the ICE/MR's 2009 as-filed Title XIX cost report. The ICF/MRs currently requiring this reconciliation process have a FYE that coincides with the SFY. Should an ICF/MR not have a FYE that coincides with the SFY, the State will obtain the costs from the cost reports overlapping the SFY and apportion the costs as appropriate. For example, if an ICF/MR has a January — December FY cost report, MHD shall use 6 month's of costs from the two cost reports overlapping the SFY.
State PlanTN# _ 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: __jAN 15 010
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ATT. 4-19D Page 228 G
4. Calculation of ICF/MR Medicaid Cost
va hee ————e———————————
i. ICF/MR Inpatient Medicaid Cost —
It is standard industry practice for ICF/MR cost reports to report the total ICF/MR costs rather than just the Medicaid cost. In determining the Medicaid cost for the ICF/MR, the total cost of serving all residents is determined because it is assumed the cost of serving a resident would not vary based on the type of resident (i.e., Medicaid, private pay, etc.). The Medicaid cost is determined by allocating the total cost based on the Medicaid utilization. The Medicaid cost is reconciled to the reimbursement to determine whether an overpayment has been made to the facility.
a. ICF/MR Inpatient Total Cost
The ICF/MR total costs are taken from Schedule B, line 160 Total Expenses, Patient Related Expenses column.
b. Medicaid Utilization
The Medicaid Utilization is found on the 1° page of the Title XIX Cost Report, section 8 Statistical Data, line 9. Title XIX share of patient days.
c. Medicaid Cost = Total Cost x Medicaid Utilization
ii. MRDD Waiver Medicaid Cost -
It is standard industry practice for ICF/MR cost reports to report the total ICF/MR costs rather than just the Medicaid cost. In determining the Medicaid cost for the ICF/MR, the total cost of serving all residents is determined because it is assumed the cost of serving a resident would not vary based on the type of resident (i.e., Medicaid, private pay, etc.). The Medicaid cost is determined by allocating the total cost based on the Medicaid utilization. The Medicaid cost is reconciled to the reimbursement to determine whether an overpayment has been made to the facility.
State Plan TN # 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: __ JAN 15 2010
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ATT. 4-19D Page 228 H
a. MRDD Waiver Total Cost
The total costs are taken from the supplemental Schedule B completed for the MRDD Waiver program, line 160 Total Expenses, Patient Related Expenses column.
b. Medicaid Utilization The Medicaid Utilization is found on the supplemental page 1 completed for the MRDD Waiver program, section 8 Statistical Data, line 9. Title XIX share of patient days.
c. Medicaid Cost = Total Cost x Medicaid Utilization
2. Medicaid Reimbursement The Medicaid reimbursement for both the inpatient payments and the MRDD Waiver
payments for each SFY will be determined from the State's Medicaid Management Information System (MMIS).
3. Determination of Federal Funding Over-Claimed
i. ICF/MR Inpatient Claim — The Medicaid inpatient cost determined above in I1!.B.1.i. shall be compared to the Medicaid reimbursement determined above in 1I1.B.2. to determine if there was an overpayment for ICF/MR inpatient services.
ii. MRDD Waiver Claim — The MRDD Waiver cost determined above in I11.B.1 ii. shall be compared to the Medicaid reimbursement determined above in III.B.2. to determine if there was an overpayment for MRDD Waiver services.
iii, Total — The difference for the ICF/MR inpatient services shall be added to the difference for the MRDD Waiver services to determine if there was an overpayment requiring an adjustment to the federal government. If the cost is greater than the reimbursement, there would not be an overpayment, or funding over-claimed, so an interim adjustment would not be necessary. If the reimbursement is greater than the cost, funding would be over-claimed and an interim adjustment would be necessary. The federal share of the overpayment would be credited-to the federal government.
State Plan TN # 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: JAN 15 2010
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ATT. 4-19D Page 228 |
4. Sample Interim Reconciliation Schedule
A sample reconciliation schedule is included as Attachment A. This sample reconciliation schedule is for Medicaid payments for SFY 2009 and is reconciled with the cost information from the facility's 2009 as-filed Title XIX cost report. As can be seen in the sample reconciliation, the Medicaid Cost exceeds the Total Medicaid Reimbursement. Therefore, no interim credit to the federal government would be necessary at this time. (Please note: This is merely a sample reconciliation schedule.)
C. Final Reconciliation of ICF/MR Inpatient Payments and MRDD Waiver Payments
Each governmentally-operated ICF/MR's interim certifiable expenditures (and any interim adjustments) will also subsequently be reconciled based on the Missouri Title XIX cost report as finalized by MHD audit staff for purposes of Medicaid reimbursement for the respective cost reporting period. The State will adjust, as necessary, the aggregate amount of interim funds claimed based on the total certifiable expenditures determined under the final reconciliation. If, at the end of the final reconciliation process, it is determined that funding was over-claimed, the overpayment will be properly credited to the federal government. If, at the end of the final reconciliation process, it is determined that a retroactive settlement is due to the ICF/MR for the inpatient payments in accordance with the approved State Plan, the underpayment will be made to the ICF/MR and the additional federal claim will be made.
The ICF/MR costs will be obtained from the Missouri Title XIX cost report, including the supplemental pages for the MRDD Waiver costs, which has been audited by the MHD staff. The MHD staff sends DMH a copy of its audit that summarizes the audited data with a letter requesting they review the audit and contact MHD staff regarding any issues. if DMH agrees with the audit, MHD will consider the audit final. If DMH doesn't agree with the audit, they may discuss the issue(s) with MPD staff to resolve them. MHD will make any changes deemed appropriate and send DMH a revised audit which MHD will consider to be final.
State PlanTN# _ 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: AN 15 2010
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ATT. 4-19D Page 228 J
The data shall be obtained from the facility's Title XIX cost report for the fiscal year being reconciled. For example, a facility's payments received for SFY 2009 will be reconciled to the costs from the ICF/MR's 2009 desk reviewed Title XIX cost report. The ICF/MRs currently requiring this reconciliation process have a FYE that coincides with the SFY. Should an ICF/MR not have a FYE that coincides with the SFY, the State will obtain the costs from the cost reports overlapping the SFY and apportion the costs as appropriate. For example, if an ICF/MR has a January — December FY cost report, MHD shall use 6 month's of costs from the two cost reports overlapping the SFY.
4. Calculation of ICF/MR Medicaid Cost i. ICF/MR Inpatient Medicaid Cost —
It is standard industry practice for ICF/MR cost reports to report the total ICF/MR costs rather than just the Medicaid cost. In determining the Medicaid cost for the ICF/MR, the total cost of serving all residents is determined because it is assumed the cost of serving a resident would not vary based on the type of resident (i.e., Medicaid, private pay, etc.). The Medicaid cost is determined by allocating the total cost based on the Medicaid utilization. The Medicaid cost is reconciled to the reimbursement to determine whether an overpayment has been made to the facility.
a. ICF/MR Inpatient Total Cost
The ICF/MR total costs are taken from Schedule B, line 160 Total Expenses, Patient Related Expenses column.
b. Medicaid Utilization
The Medicaid Utilization is found on the 1* page of the Title XIX Cost Report, section 8 Statistical Data, line 9. Title XIX share of patient days.
c. Medicaid Cost = Total Cost x Medicaid Utilization
State Plan TN # 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: AN 1.5 2010
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ATT. 4-19D Page 228 K
ii. MRDD Waiver Cost —
It is standard industry practice for ICF/MR cost reports to report the total ICF/MR costs rather than just the Medicaid cost. In determining the Medicaid cost for the ICF/MR, the total cost of serving all residents is determined because it is assumed the cost of serving a resident would not vary based on the type of resident (i.e., Medicaid, private pay, etc.). The Medicaid cost is determined by allocating the total cost based on the Medicaid utilization. The Medicaid cost is reconciled to the reimbursement to determine whether an overpayment has been made to the facility.
a. MRDD Waiver Total Cost
The ICF/MR total costs are taken from the supplemental Schedule B completed for the MRDD Waiver, line 160 Total Expenses, Patient Related Expenses column.
b. Medicaid Utilization The Medicaid Utilization is found on the supplemental 1* page of the Title XIX Cost Report, section 8 Statistical Data, line 9. Title XIX share of patient days.
c. Medicaid Cost .= Total Cost x Medicaid Utilization
2. Medicaid Reimbursement
The Medicaid reimbursement for both the inpatient payments and the MRDD Waiver payments for each SFY will be determined from the State's Medicaid Management Information System (MMIS).
State Plan TN # 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: __ JAN 15 2010
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ATT. 4-19D Page 228 L
3. Determination of Federal Funding Over-Claimed
i. 1ICF/MR Inpatient Claim — The Medicaid inpatient cost determined above in IlI.C.1.i. shall be compared to the Medicaid reimbursement determined above in Il1.C.2. to determine if there was an overpayment for ICF/MR inpatient services. As indicated previously, the state-operated ICF/MR inpatient reimbursement is a retrospective system. As set forth in the approved State Plan, a retroactive settlement is done at the end of the state fiscal year after the cost report has been audited for any underpayment or overpayment. If the cost is greater than the reimbursement, the facility has been underpaid; a payout will be made to the facility and the additional federal claim will be made. If the cost is less than the reimbursement, the facility has been overpaid; a recoupment from the facility will be done. The overpayment will be combined with the difference between the cost and reimbursement for the MRDD Waiver below in iii. to determine if there is any federal funding over-claimed. This retroactive settlement will be reflected in the final reconciliation and the difference between in the cost and reimbursement for the ICF/MR inpatient services will be zero.
ii. MRDD Waiver Claim - The MRDD Waiver cost determined above in I1I.C.1.ii. shall be compared to the Medicaid reimbursement determined above in III.C.2. to determine if there was an overpayment for MRDD Waiver services.
iii. Total — The difference for the ICF/MR inpatient services shall be added to the difference for the MRDD Waiver services to determine if there was an overpayment requiring an adjustment to the federal government. If the total cost is greater than the total reimbursement, there would not be an overpayment, or federal funding over-claimed, so a final adjustment would not be necessary. If the total reimbursement is greater than the total cost, the federal funding would be over-claimed and a final adjustment would be necessary. The federal share of the overpayment would be credited to the federal government.
4. Sample Final Reconciliation Schedule
A sample reconciliation schedule is included as Attachment B. This sample reconciliation schedule is for Medicaid payments for SFY 2009 and is reconciled with the cost information from the facility's 2009 as-filed Title XIX cost report. As can be seen in the sample reconciliation, the Medicaid Cost exceeds the Total Medicaid Reimbursement. Therefore, no final credit to the federal government would be necessary. (Please note: This is merely a sample reconciliation schedule.)
State Plan TN # Q9-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: JAN 15 2010
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ATT. 4-19D Page 228 M
Attachment A
Interim Reconciliation of Certified Public Expenditures & Related Payments
SFY 2009
Inpatient Reimbursement A. ICF/MR Cost Total Expenses Medicaid Utilization Medicaid Cost
B. Medicaid Reimbursement
Difference - Cost Exceeds Reimbursement MRDD Waiver A. MRDD Waiver Cost
Total Expenses
Medicaid Utilization
Medicaid Cost
B. Medicaid Reimbursement
Difference — Cost Exceeds Reimbursement
Total ICF/MR Services Difference — Cost Exceeds Reimbursement
Interim Adjustment — Total Overpayment FFP - SFY 2009 Amount Due to CMS
State PlanTN# _ 09-10 Effective Date: __ 10/01/2009 Supersedes TN # _New Page Approval Date: AN 15 2010
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ATT. 4-19D Page 228 N
Attachment B
Final Reconciliation of Certified Public Expenditures & Related Payments SFY 2009
Inpatient Reimbursement A. ICF/MR Cost Total Expenses Medicaid Utilization Medicaid Cost
B. Medicaid Reimbursement
Difference - Cost exceeds Reimbursement — Underpayment Retroactive Settlement Paid Difference — after Retroactive Settlement
MRDD Waiver
A. MRDD Waiver Cost Total Expenses Medicaid Utilization Medicaid Cost
B. Medicaid Reimbursement
Difference — Cost Exceeds Reimbursement
Total ICF/MR Services Difference — Cost Exceeds Reimbursement Interim Reconciliation — Paid to CMS Final Reconciliation — Due to / from CMS
FFP - SFY 2009 Amount Due to / from CMS
State Plan TN # 09-10 Effective Date: _ 10/01/2009 Supersedes TN # _New Page Approval Date: AN 7-5-2010
(spa)(mo-09-10)(attachment)(page-15)Page 15#
: ‘ OS Notification
State/Title/Plan Number: Missouri 09-010
Type of Action: SPA Approval
Required Date for State Notification: 02/15/2010
Fiscal Impact: FFY 10 $-0- FFY 11 $-0-
Number of Services Provided by Enhanced Coverage, Benefits or Retained Enrollment:__ 0
Number of Potential Newly Eligible People: 0 or Eligibility Simplification: No
Provider Payment Increase: No or Decrease: No Delivery System Innovation: No
Number of People Losing Medicaid Eligibility: 0 Reduces Benefits: No
Detail:
Effective for services on or after October 1, 2009, this amendment incorporates Intermediate Care Facilities for persons with Mental Retardation (ICF/MR) certified public expenditure protocol into the Missouri Medicaid State plan. CPEs are used to fund Medicaid services at State-operated ICF/MR habilitation centers.
Other Considerations: This plan amendment has not generated significant outside interest and we do not recommend the Secretary contact the governor.
This OSN has been reviewed in the context of the ARRA and approval of the OSN is not in violation of ARRA provisions.
CMS Contact:
Tim Weidler (816) 426-6429 National Institutional Reimbursement Team
(spa)(mo-09-10)(form-cms-179)Missouri Medicaid SPA MO-09-10: Form CMS-179 (approved January 15, 2010, effective October 1, 2009)#
(spa)(mo-09-10)(form-cms-179)(page-1)Page 1#
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1” TRANSMITTAL NUMBER: _ | 2. STATE STATE PLAN MATERIAL Missouri FOR: HEALTH CARE FINANCING ADMINISTRATION o. 9 ~ 1 0
3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT
(MEDICAID) 4. PROPOSED EFFECTIVE DATE
TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES October 1, 2009
5. TYPE OF PLAN MATERIAL (Check One):
[DD NEW STATE PLAN (1 AMENDMENT TO BE CONSIDERED AS NEW PLAN { AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)
7, FEDERAL BUDGET IMPACT:
6. FEDERAL STATUTE/REGULATION CITATION:
42 CER 447 Subpart C a. FFY __2010 $__0 b. FFY _2011 §_0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDES PLAN SECTION OR ATTACHMENT (if Applicable): Attachment 4-19D N/A - all new material
Pages 228 A, 228 B, 228 C, 228 D, 228 E, 228 F, 228 G, 228 H, 2281, 2283, 228 K, 228 L, 228 M and 228 N
10. SUBJECT OF AMENDMENT: This amendment provides for the inclusion 0 Medicare and Medicaid Services.
YM. over 5 REVIEW (Check One) ) GOVERNOR’S OFFICE REPORTED NO COMMEN | OTHER, AS SPECIFIED:
O COMMENTS OF GOVERNOR’S OFFICE ENCLOSED
f the ICF/MR CPE Protocol in Missouri's Medicaid State Plan, as requested by the Centers for
Ol NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16: RETURN TO: MO HealthNet Division P.O. Box 6500
. 4 Jefferson City, MO 65102
2.
13. TYPE NAME: Ronald J. Levy 14, TITLE: Director
15. DATE SUBMITTED: “ / 17/0 y
FOR REGIONAL OFFICE USE ONLY
17, DATE RECEIVED: [ \Ovember 18, 220% [ 18: DATE APPROVED: O1-1S~10 y PLAN APPROVED - ONE COPY ATTACHED
ian 19. EFFECTIVE DATE OF APPROVED MATERIAL: IGN; R REGIONAL OFFICIAL: oct - 1 2009 AT oun. mM TITLE
21. TYPED NAME: 2 Wilham Lasowsx “De pury Diverter, CM S50
23. REMARKS:
FORM HCFA-179 (07-92)
(spa)(mo-11-17)(approval-document)Missouri Medicaid SPA MO-11-17: Approval Document (approved March 2, 2012, effective October 1, 2012)#
(spa)(mo-11-17)(approval-document)(page-1)Page 1#
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106
Division of Medicaid and Children's Health Operations March 5, 2012
Brian Kinkade, Acting Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, Missouri 65102-1527
Dear Mr. Kinkade:
On December 6, 2011, the Center for Medicare & Medicaid Services (CMS) received Missouri’s State Plan Amendment (SPA) transmittal #11-17, which adds restrictions regarding children under the age of 17 being transported under the non-emergency medical transportation program to be accompanied by a parent or adult. It also adds coverage for foster care participants 18-21 years of age.
This SPA was approved on March 2, 2012 with an effective of October 1, 2011 as requested by the State.
Enclosed is a copy of the CMS 179 form as well as the approved page for incorporation into the Missouri State plan.
I appreciate the significant amount of work that your staff dedicated to getting this SPA approved and the cooperative way in which we achieved this much-desired outcome. If you have any questions concerning this SPA, please contact me at (816)426-5925 or have your staff contact Rhonda Wells or Debbie Read at (816) 426-5925 or Rhonda.Wells@cms.hhs.gov
Sincerely,
/s/
James G. Scott
Associate Regional Administrator
for Medicaid and Children’s Health Operations
cc: Ian McCaslin
(spa)(mo-11-17)(attachment)Missouri Medicaid SPA MO-11-17: Attachment (approved March 2, 2012, effective October 1, 2012)#
(spa)(mo-11-17)(attachment)(page-1)Page 1#
Revised Submission |, 23.12
Replacement Page ATTACHMENT 3.1-A Page 9-2 Rev. 11/2011
The broker maintains a toll-free telephone line to accept NEMT requests from participants. Based on the information obtained on the call, the broker will assure all NEMT criteria is met and arrange the least expensive method of transportation that meets the needs of the client. The call center shall have sufficient staff to perform functions for a least nine (9) consecutive hours Monday through Friday. NEMT services shall be available 24 hours per day, seven (7) days per week, when medically necessary.
Interpreter services will be available, as necessary, to ensure participants are able to i communicate with the broker. Customer service policies and procedures will be implemented to address call wait time, call abandonment, voice mail routing and response, telephone quality, call tracking and fax and written correspondence.
The broker shall assure all participants under the age of 17 are only transported with a parent/guardian. The parent/guardian may designate another adult (i.c., family member or friend) to accompany a child under the age of 17.
The broker shall authorize and arrange the least expensive and most appropriate ancillary services. For children under the age of 21, ancillary services may include an attendant and/or parent/guardian to accompany the child if the medical appointment requires an overnight stay.
The broker must maintain a provider network which consists of various modalities to support the transportation needs of participants state-wide. The broker shall ensure the safety of all participants while being transported. All vehicles shall be in compliance with federal motor vehicle safety standards. The State does not require a specific } reimbursement methodology be used by the broker when subcontracting with i transportation providers. The broker is responsible for tracking and reporting all trip information and provider adequacy to the Medicaid State Agency.
The broker shall have a system in place for participants to access the state agency's fair hearing system.
The broker shall implement internal controls, policies and procedures to prevent, detect, review and report to the Medicaid state agency instances of suspected fraud and abuse by providers, subcontractors and participants.
TN No.: MO 11-17 Effective Date _ October 1, 2011 Supersedes TN No.: 10-05 Approval Date MAR 02 2012
(spa)(mo-11-17)(attachment)(page-2)Page 2#
ATTACHMENT 3.1-A Page 9-5 OMB No.
(5) The broker contract will provide transportation to the following categorically needy optional populations:
TN No.:
(J Optional low-income pregnant women EX] Optional low-income infants
C1 Optional targeted low-income children
EX] Individuals under 21 who are under State adoption assistance agreements
Individuals under age 21 who were in foster care on their 18° birthday
(] Individuals who meet income and resource requirements of AFDC or SSI
C) Individuals who would meet the income & resource requirements of AFDC if child care costs were paid from earnings rather than by a State agency
1] Individuals who would be eligible for AFDC if State plan had been as broad as allowed under Federal law
C] Individuals who would be eligible for AFDC or SSI if they were not in a medical institution
1 Individuals infected with TB
Individuals screened for breast or cervical cancer by CDC program
U1 Individuals receiving COBRA continuation benefits
EX] Individuals in special income level group, in a medical institution for at least
30 consecutive days, with gross income not exceeding 300% of SSI income standard
Individuals receiving home and community based waiver services who would only be eligible under State plan if in a medical institution
MO 11-17 Effective Date__ October 1 2011
Supersedes TN No.: _ 06-09 Approval Date MAR 0 2 pil 2
(spa)(mo-11-17)(form-cms-179)Missouri Medicaid SPA MO-11-17: Form CMS-179 (approved March 2, 2012, effective October 1, 2012)#
(spa)(mo-11-17)(form-cms-179)(page-1)Page 1#
DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH CARE FINANCING ADMINISTRATION OMONO Ose nas TRANSMITTAL AND NOTICE OF APPROVAL OF T. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL Missouri FOR: HEALTH CARE FINANCING ADMINISTRATION 1 J- 1 7
3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)
TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES
4. PROPOSED EFFECTIVE DATE
October 1, 2011
5. TYPE OF PLAN MATERIAL (Check One):
(1 NEW STATE PLAN (1 AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT
COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)
6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 431.53 42 CFR 440.170
7, FEDERAL BUDGET IMPACT:
a. FFY 2012 =$_0 b. FFY_2013 $_0
8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:
Attachment 3.1-A, pages 9-2 and 9-5
9. PAGE NUMBER OF THE SUPERSEDES PLAN SECTION OR ATTACHMENT (If Applicable):
Attachment 3.1-A, pages 9-2 and 9-5
10. SUBJECT OF AMENDMENT:
Adds restriction regarding children under the age of 17 being transported under the non-emergency medical transportation program. Add coverage for foster care participants 18-21 years of age.
11. GOVERNOR’S REVIEW (Check One) ee GOVERNOR'S OFFICE REPORTED NO COMME (2 COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (] No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
(1) OTHER, AS SPECIFIED:
12. SIGNATURE OF STATE AGENCY OFFICIAL:
CO
16: RETURN TO:
MO HealthNet Division P.O. Box 6500
13. TYPE NAME: Brian Kinkade
Jefferson City, MO 65102
14, TITLE: Interim Director
15. DATE SUBMITTED: December 6, 20141
FOR REGIONAL OFFICE USE ONLY
17. DATERECEIVED: Aygo rember 6 QO)
[.18: DATE APPROVED: M\arch 9. OODIQ.
PLAN APPROVED - ONE COPY ATTACHED
19, EFFECTIVE DATE OF APPROVED MATERIAL:
October 1Qo0i))
20. aD
21. TYPED NAME:
James G. Scott
sori atE Regional Rramistrator
23, REMARKS:
FORM HCFA-179 (07-92)
(spa)(mo-13-10-m)(approval-document)Missouri Medicaid SPA MO-13-10 M: Approval Document (approved December 11, 2013, effective July 1, 2013)#
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Table of Contents State/Territory Name: Missouri State Plan Amendment (SPA) #: 13-10 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
(spa)(mo-13-10-m)(approval-document)(page-2)Page 2#
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106
Division of Medicaid and Children's Health Operations
December 11, 2013
Brian Kinkade, Interim Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, Missouri 65102-1527
Dear Mr. Kinkade:
On September 18, 2013, the Centers for Medicare & Medicaid Services (CMS) received Missouri’s State Plan Amendment (SPA) transmittal #13-10, an Interagency Agreement between the Missouri Department of Elementary and Secondary Education and the Missouri Department of Social Services. This agreement is for Missouri First Step services under Part C of the Individuals with Disabilities Education Act (IDEA).
This SPA was approved on December 10, 2013, with an effective date of July 1, 2013, as requested by the state. Enclosed is a copy of the CMS 179 form, as well as, the approved pages for incorporation into the Missouri State Plan.
The Regional Office reviewed this submission as a “prototype” per request of the state in a letter dated October 10, 2013. If you have any questions concerning this SPA, please contact Deborah Read at (816) 426-5925 or Deborah.Read@cms.hhs.gov.
Sincerely,
//s//
James G. Scott
Associate Regional Administrator
for Medicaid and Children’s Health Operations
cc: Jennifer Tidball
(spa)(mo-13-10-m)(approval-document)(page-3)Page 3#
DEPARTMENT OF HEALTH AND HUMAN SERVICES HEAL1H CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 1. TRANSMITTAL NUMBER: 1 3 - 1 0 3. PROGRAM IDENTIFICATION: FORM APPROVED OMB NO. 0938-0193 2. STATE Missouri "'!ITLE XI~ OF THE SOCIAL SECURITY ACT UVIEDICAID I . 4. PROPOSED EFFECTIVE DATE July 1, 2013 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CFR 431 Subpart M a. FFY 13 $ 0 b. FFY 14 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 4.16-210 10. SUBJECT OF AMENDMENT: 9. PAGE NUMBER OF THE SUPERSEDES PLAN SECTION OR ATIACHMENT (If Applicable): Replaces current Attachment 4.16-210 and 4.16-18 Interagency Agreement between the Missouri Department of Elementmy and Secondary Education and the Missouri Department of Social Services for Missouri First Step services under Part C of the Individuals with Disabilities Education Act (IDEA). OR'S REVIEW (Check One) GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 15. DATE SUBMITTED: 0 OTHER, AS SPECIFIED: 16: RETURN TO: MO HealthNet Division 615 Howerton Court P.O. Box 6500 Jefferson City, MO 65102 September 18, 2013 December 10, 2013 July 1, 2013 James G. Scott Associate Regional Administrator for Medicaid and Children's Health Operations //s//
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Attachment 4.16-210 Interagency Agreement Between the Department of Elementary and Secondary Education And The Department of Social Services For Missouri First Steps Services under Part C of the Individuals with Disabilities Education Act (IDEA) I STATEMENT OF PURPOSE This agreement reflects the cooperative and mutual understanding between the Missouri Department of Social Services (DSS), MO HealthNet Division (MHD), and the Missouri Department of Elementary and Secondary Education (DESE), Office of Special Education (OSE) to fulfill their regulatory requirements, maximize resources, reduce duplication of services, and provide a statewide system of early intervention services that is coordinated, comprehensive, and multidisciplinary in nature. This agreement complies with the requirements of 45 CFR 95.507(6). DSS is the single state agency designated to administer the MO HealthNet program in Missouri and MHD is the division within DSS that directly manages MO HealthN et program operations, except for the determination of participant eligibility for the program, which is the responsibility of the Family Support Division. DESE is the statutorily authorized state agency responsible for ensuring the provision of early intervention services to eligible infants and toddlers and their families under Part C of the Individuals with Disabilities Education Act (IDEA), known as First Steps in Missouri. OSE is the office within DESE that directly manages First Steps program operations. This agreement identifies the responsibilities and obligations of DSS and DESE for establishing an Organized Health Care Delivery System (OHCDS) and payment for early intervention services that are deemed medically necessary through the OHCDS covered by Title XIX and Title XXI of the Federal Social Security Act for MO HealthNet eligible recipients. II MUTUAL OBJECTIVES To assure that the recipients of service under this agreement are afforded services and supports to achieve the greatest possible adjustment and functioning within their families and communities, and thereby to reduce or prevent the need for institutionalism. Further, to assure that services are provided under this agreement are provided in an efficient and cost effective manner, reduce duplication of services, and are in accordance with the standards, policies and procedures of the First Steps program and the MO HealthNet program. Services: As mutually agreed upon, services to be covered under the OHCDS designation include: MO HealthNet Services • Durable Medical Equipment • HCY Developmental Assessment • Hearing Aid • Optical • Personal Care • Physician • Psychology Counseling • Therapy State Plan TN No. 15-fo Supersedes TN No. 02-16 Corresponding First Steps Services • Assistive Technology • Developmental Assessment • Audiology • Vision Services • Nursing, Health Services and Family Training • Medical Evaluation/Diagnosis • Counseling, Social Work, Psychological Services • Occupational, Physical, and Speech Therapy Approval Date_-:-_ Effective Date diJ.iy' I J zo f.3 December 10, 2013
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Attachment 4.16-21 0 Managed Care Services: MO HealthNet Managed Care health plans shall not be financially liable for early intervention services included in the Individualized Family Service Plan (IFSP) if listed above. These services· are available outside the MO HealthNet Managed Care health plans through a carve-out process and shall be reimbursed on a fee-for-service basis. Payments: Fees shall not be charged for services a child is otherwise entitled to receive at no cost (child find activities, evaluation and assessment, service coordination, implementation of procedural safeguards, and the administration and coordination of activities). The use of MO HealthNet for First Steps services shall not: • Decrease available lifetime coverage for MO HealthNet or any other insured benefit for the child or family • Result in the child's parents paying for services that would otherwise be covered by MO HealthNet • Result in any increase in premiums or discontinuation of MO HealthNet for the child or family • Risk loss of eligibility for the child or family for home or community-based waivers based on aggregate health-related expenditures All payments, including interim payments, shall be made in accordance with each agency's applicable federal and state laws and regulations. Dispute Resolution: Any and all services identified in the child's IFSP, or which the parent is entitled to, shall not be delayed or denied during the internal or interagency dispute resolution and until the dispute is resolved. OSE shall use First Steps funds to pay for the identified services until the dispute is resolved and responsibility is assigned. Internal Agency Dispute Resolution: Each agency shall follow their procedures for internal disputes within the agency. For DESE, if internal dispute resolution is unsuccessful within OSE or another office within DESE, the dispute shall be resolved by the Commissioner of Education after going through the appropriate administrative levels within each office. For DSS, if internal dispute resolution is unsuccessful within MHD or another office within DSS, the dispute shall be resolved by the Director of Social Services after going through the appropriate administrative levels within each ?ffice. Interagency Dispute Resolution: DSS and DESE shall follow the procedures outlined below for disputes between the two agencies. • DESE staff involved in the dispute shall notify the Assistant Commissioner (AC) of OSE and present the information related to the dispute. • The AC shall conduct a review of all information and make a determination of responsibility. If the AC determines OSE is responsible, the dispute shall be resolved at that time and OSE shall claim responsibility. If the AC determines OSE is not responsible, the AC shall schedule a meeting with the MHD Director within three weeks of the AC's review. • If the AC ofOSE and the MHD Director are unable to come to a mutual agreement of responsibility at the meeting, the dispute shall be handed over to the Commissioner of Education and the Director of DSS. • The Commissioner of Education shall conduct a review of all information and make a determination of responsibility. If the Commissioner ofEducation determines DESE is State Plan TN No. 13-10 Supersedes TN No. 02-16 1 Approval Date--:----:---:- Effective Date..JIA...~ 1,;2013 December 10, 2013
(spa)(mo-13-10-m)(approval-document)(page-6)Page 6#
Attachment 4.16-210 responsible, the dispute shall be resolved at that time and DESE shall claim responsibility. If the Commissioner of Education determines DESE is not responsible, the Commissioner of Education shall schedule a meeting with the Director ofDSS within three weeks ofthe review by the Commissioner of Education. • If the Commissioner of Education and the Director ofDSS are unable to come to a mutual agreement of responsibility, the dispute shall be handed over to the Commissioner of the Office of Administration. • The determination made by the Commissioner of the Office of Administration shall be the final decision of who assumes responsibility. • OSE shall make arrangements with the responsible agency for reimbursement of any expenditures incurred. m RESPECTIVE DUTIES The Missouri Department of Social Services, MO HealthNet Division agrees to: 1. Allow DESE to enroll in the MO HealthNet program as an OHCDS as set forth in 42 CFR 44 7.10 for early intervention services provided through First Steps as described herein and provide DESE with appropriate provider numbers. 2. Allow DESE to submit claims in order to draw the federal participation portion of payment and pay to DESE for early intervention services provided through First Steps as described herein. 3. Assist DESE in preparing and reviewing material to be published by DESE regarding MO HealthNet claims and payment, including policy memoranda, materials, reports, etc. 4. Maintain the confidentiality of client personal identifiable information received from DESE and use that information only in the activities authorized under this agreement. 5. Collaborate in the development of periodic quality assurance and utilization reviews by DESE. 6. Meet and consult on a regular basis on issues related to this agreement. The Missouri Department of Elementary and Secondary Education agrees to: 1. Determine eligibility criteria for early intervention services through the First Steps program in accordance with IDEA and state regulations. 2. Provide early intervention services in accordance with the child's IFSP as authorized under IDEA and state regulations. 3. Ensure early intervention services through First Steps are provided by qualified personnel that meet state requirements and MO HealthNet criteria. First Steps licensure and credentials for enrolled providers are outlined in the Missouri State Plan for First Steps at: http://dese.mo.gov/se/compliance/specedlawsregs.html. MO HealthNet provider requirements are outlined at: http://manuals.momed.com/manuals/. State Plan TN No. i3-Jb Supersedes TN No. 02-16 Approval Date-r--- Effective Date3u U.1 I 1.).013 December 10, 2013
(spa)(mo-13-10-m)(approval-document)(page-7)Page 7#
Attachment 4.16-210 4. Ensure that Part C funds are not used, except on an interim basis, to satisfY a financial commitment for services that would otherwise have been paid for from another public or private source. Funding is received from various sources, thus creating a System of Payment. The policy related to the System of Payments is located at: http://www.dese.mo.gov/se/fs/FCPmainpg.htm. 5. Complete the enrollment process for an OHCDS provider designation as set forth in 42 CFR 447.10. 6. Sign the Missouri Medicaid Provider Enrollment Application for the services described herein and agree to all requirements of the participation agreements. 7. Process claims under the OHCDS designation. 8. Certify the state match of funds based on the current Federal Medical Assistance Percentage (FMAP) rate for the services described herein and billed by DESE to MO HealthNet. 9. Monitor contractors and providers for procedural compliance with laws and regulations. 10. Report instances of provider non-compliance related to MO HealthNet billing to MO HealthNet and jointly pursue any action necessary and appropriate to remedy the non- compliance. 11. Facilitate the relationship between First Steps and MO HealthNet Managed Care health plans. 12. Upon request, provide a report of all First Steps active providers, including the name, license number if applicable, and social security number. 13. Be responsible for any federal funds related to MO HealthNet billing and reimbursement which are deferred and/or ultimately disallowed arising from a failure by DESE to comply with federal regulations. 14. Maintain the confidentiality of client personal identifiable and eligibility information received from MO HealthNet and use that information only in the activities authorized under this agreement. I 5. Account for the activities under this agreement in accordance with the provision of OMB Circular A87 and 45 CFR Part 74 and 95 State Plan TN No. /3 -lo Supersedes TN No. 02-16 Approval Date--.--__ Effective Dat~ 11 <2.() 13 December 10, 2013
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Attachment 4.16-210 IV TERMS OF THIS AGREEMENT The effective date of this agreement shall be upon execution. This agreement may be modified at any time by the written agreement of both parties and it may be canceled by either party after giving thirty (30) days notice · writing to the other party. ----:-- Brian Kinkade, Interim Director Department of Social Services
Chris L. Nicastro, Ph.D., Commissioner Department of Elementary and Secondary Education State Plan TN No. /3-/C Supersedes TN No. 02-16 6/3/2013 Date Approval Date..-__ Effective Oat~ I ).Q0/3 December 10, 2013
(spa)(mo-13-0024-mm2)(approval-document)Missouri Medicaid SPA MO-13-0024-MM2: Approval Document (approved December 29, 2014, effective October 1, 2013)#
(spa)(mo-13-0024-mm2)(approval-document)(page-1)Page 1#
Table of Contents
State/Territory Name: MO State Plan Amendment (SPA) #: 13-0024-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter (delete if not applicable) 3) CMS 179 Form/Summary Form (with 179-like data) 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan (delete if not applicable)
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106
Division of Medicaid and Children's Health Operations
December 29, 2014
Brian Kinkade, Director Department of Social Services Broadway State Office Building PO Box 1527 Jefferson City, Missouri 65102
Dear Mr. Kinkade:
Enclosed is an approved copy of Missouri’s state plan amendment (SPA) 13-0024-MM2, which was submitted to CMS on December 13, 2013. SPA 13-0024-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Missouri’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.
The approval of SPA 13-0024-MM2 includes full approval of your state’s alternative single streamlined paper application. The state is using an interim alternative single streamlined online application and by March 1, 2015 will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.
Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of Missouri’s approved state plan: S94, pages S94-1 and S94-2 Attachment 1 – Alternative single streamlined paper application Attachment 2 – Statement of use with respect to the alternative single, streamlined online application Attachment 3 – Statement with respect to the coordination of eligibility and enrollment
CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Karen Hatcher at (816) 426-5925 or Karen.Hatcher@cms.hhs.gov.
Sincerely,
//s//
James G. Scott
Associate Regional Administrator
for Medicaid and Children’s Health Operations
cc: Joe Parks, M.D.
(spa)(mo-13-0024-mm2)(approval-document)(page-3)Page 3#
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106
Division of Medicaid and Children's Health Operations
December 29, 2014
Brian Kinkade, Director Department of Social Services Broadway State Office Building PO Box 1527 Jefferson City, Missouri 65102
Dear: Mr. Kinkade:
This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) 13-0024-MM2, which was submitted to CMS on December 31, 2013. Our review of this submission included a review of the alternative single streamlined paper and online applications developed by the state. Until March 1, 2015 the state is using an interim alternative single streamlined online application. By March 1, 2015, the state will implement a revised application incorporating the changes indicated below:
Necessary changes: Date by which changes will be completed: Missouri will add language to the income screen to clarify that applicants should not provide information about income types that are not countable under MAGI rules, such as child support, Veterans’ benefits, and SSI, unless the applicant is potentially eligible on a basis other than MAGI. March 1, 2015
Please submit the revised alternative single, streamlined online application to CMS for review no later than February 15, 2015, to ensure approval by March 1, 2015. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov. If you have any questions about this letter or need any additional information, please contact Karen Hatcher at (816) 426-5925 or Karen.Hatcher@cms.hhs.gov.
Sincerely,
//s//
James G. Scott
Associate Regional Administrator
for Medicaid and Children’s Health Operations
cc: Joe Parks, M.D.
(spa)(mo-13-0024-mm2)(approval-document)(page-4)Page 4#
State/Territory name: Missouri Submitted By: Debbie Meller Last Revision Date: Dec 26, 2014 Submit Date: Jan 9, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-13-0024 Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M Federal Budget Impact Federal Fiscal Year Amount First Year 2013 $ 0.00 Second Year 2014 $ 0.00 Subject of Amendment This amendment certifies that Missouri has an alternative single, streamlined application and a general eligibility process that meets the requirements established under the Affordable Care Act (ACA) and approved by the Secretary. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 01/05/2015 Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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Page 2 of 2 Medicaid Eligibility Indicate the other electronic means below: Name of Method Description + Smart Phone Participants can send via internet enabled phone. x The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency ■ If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ 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 40 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. Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION
Paper Application Online Application
TRANSMITTAL NUMBER:
MO – 13-0024-MM2
STATE:
Missouri
Through March 1, 2015, the state is using an interim alternative single streamlined application. After March 1, 2015, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.
Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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Application for Health Coverage & Help Paying Costs Thing t
Use this application • Affordable private health insurance plans that offer comprehensive coverage to to see what help you stay well • A new tax credit that can immediately help pay your premiums for coverage choices health coverage you qualify for • Free or low-cost insurance from MO HealthNet You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a family of 4).
Who can use this • Use this application to apply for anyone in your family. Application? • Apply even if you or your child already has health coverage. You could be eligible for lower-cost or free coverage. • Families that include immigrants can apply. You can apply for your child even if you are not eligible for coverage. Applying will not affect your immigration status or chances of becoming a permanent resident or citizen. • If someone is helping you fill out this application, you may need to complete Appendix C.
Apply faster Apply faster online at mydss.mo.gov. online
What you may • Social Security Numbers (or document numbers for any legal need to apply immigrants who need insurance) • Employer and income information in your family (for example, from paystubs, W-2 forms, or wage and tax statements) • Policy numbers for any current health insurance • Information about any job-related health insurance available to your family
Why do we ask for We ask about income and other information to let you know what coverage this information? you qualify for and if you can get any help paying for it. We will keep all the information you provide private and secure, as required by law.
What happens Send your complete, signed application to the address on page 7. If you next? do not have all the information we ask for, sign and submit your application anyway. We will follow-up with you. You will get instructions on the next steps to complete your health coverage. If you do not hear from us, call 1-855-373-9994. Filling out this application does not mean you have to buy health coverage. NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994. MO 886-4537 (11-14)
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Get help with this • Online: mydss.mo.gov application • Phone: Call our Contact Center at 1-855-373-9994. • In person: Any local Family Support Division office or there may be counselors in your area who can help. Visit HealthCare.gov or call 1-800-318-2596 for more information. • En Español: Llame a nuestro centro de ayuda gratis al 1-855-373-9994. NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994. MO 886-4537 (11-14)
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Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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STEP 1 Tell us about yourself. Did you obtain this application from a: State Public School Licensed Child Care Provider (We need one adult in the family to be the contact person for your application.) Other 1. First name, Middle name, Last name, & Suffix
2. Home address (Leave blank if you do not have one.) 3. Apartment or suite number 4. City 5. State 6. ZIP code 7. County 8. Mailing address (if different from home address) 9. Apartment or suite number 10. City 11. State 12. ZIP code 13. County 14. Phone number ( ) – 15. Other phone number ( ) – 16. Do you want to get information about this application by email? Yes No Email address: 17. Preferred spoken or written language (if not English) STEP 2 Tell us about your family. Who do you need to include on this application? Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return. (You do not need to file taxes to get health coverage).
DO Include: • Yourself • Your spouse • Your children under 21 who live with you • Your unmarried partner who needs health coverage • Anyone you include on your tax return, even if they do not live with you • Anyone else under 21 who you take care of and lives with you
You DO NOT have to include: • Your unmarried partner who does not need health coverage • Your unmarried partner’s children • Your parents who live with you, but file their own tax return (if you are over 21) • Other adult relatives who file their own tax return
The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can. Complete Step 2 for each person in your family. Start with yourself, then add other adult and children. If you have more than 2 people in your family, you will need to make a copy of the pages and attach them. You do not need to provide immigration status or a Social Security Number (SSN) for family members who do not need health coverage. We will keep all the information you provide private and secure as required by law. We will use personal information only to check if you are eligible for health coverage. NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994.
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Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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STEP 2: PERSON 1
(Start with yourself) Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you do not file a tax return, remember to still add family members who live with you. 1. First name, Middle name, Last name, & Suffix 2. Relationship to you? SELF 3. Date of birth (mm/dd/yyyy) 4. Sex Male Female 5. Social Security Number (SSN) - - We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you do not want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. If someone wants help getting a SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.
6. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you do not file a federal income tax return.) YES. If yes, please answer questions a–c. NO. If no, skip to question c. a. Will you file jointly with a spouse? Yes No If yes, name of spouse: b. Will you claim any dependents on your tax return? Yes No If yes, list name(s) of dependents: c. Will you be claimed as a dependent on someone’s tax return? Yes No If yes, please list the name of the tax filer: How are you related to the tax filer? 7. Are you pregnant? Yes No a. If yes, how many babies are expected during this pregnancy? 8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.) YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 3. Leave the rest of this page blank.
9. Do you have a physical, mental or emotional health conditions that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? Yes No 10. Are you a U.S. citizen or U.S. national? Yes No 11. If you are not a U.S. citizen or U.S. national, do you have eligible immigration status? Yes. Fill in your document type and ID number below. a. Immigration document type b. Document ID number c. Have you lived in the U.S. since 1996? Yes No d. Are you or your spouse or parent a veteran or an active-duty member of the U.S. military? Yes No 12. Do you want help paying for medical bills from the last 3 months? Yes No 13. Do you live with at least one child under the age of 19, and are you the main person taking care of this child? Yes No 14. Are you a full-time student? Yes No 15. Were you in foster care at age 18 or older? Yes No 16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican Mexican American Chicano/a Puerto Rican Cuban Other 17. Race (OPTIONAL—check all that applies.) White American Indian or Filipino Vietnamese Guamanian or Chamorro Black or African Alaska Native Japanese Other Asian Samoan American Asian Indian Korean Native Hawaiian Other Pacific Islander Chinese
Other NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994.
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STEP 2: PERSON 1 (Continue with yourself) Current Job & Income Information Employed If you are currently employed, tell us about your income. Start with question 18. Not employed Skip to question 28. Self-employed Skip to question 27. CURRENT JOB 1: 18. Employer name and address 19. Employer phone number ( ) – 20. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly $ 21. Average hours worked each WEEK CURRENT JOB 2: (if you have more jobs and need more space, attach another sheet of paper.) 22. Employer name and address 23. Employer phone number ( ) – 24. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly $ 25. Average hours worked each WEEK 26. In the past year, did you: Change jobs Stop working Start working fewer hours None of these 27. If self-employed, answer the following questions: a. Type of work b. How much net income (profits once business expense are paid) will you get from self-employment this month.
$ 28. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: Income types including child support, veteran’s benefits, gifts, Supplemental Security Income (SSI), American Indian/Alaskan Payments, and educational assistance does not count for certain types of MO HealthNet Assistance. Only tell us about these types of income if you are applying for someone who is age 65 or older, or who has a disability. None
Alimony received $ How often? Unemployment $ How often? Net farming/fishing $ How often? Pensions $ How often? Net rental/royalty $ How often? Social Security $ How often? Other income Retirement accounts $ How often? Type: $ 29. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You should not include a cost that you already considered in your answer to net self-employment (question 27b). Alimony paid $ How often? Other deductions $ How often? Student loan interest $ How often? Type: 30. YEARLY INCOME: Complete only if your income changes from month to month. If you do not expect changes to your monthly income, skip to the next person. Your total income this year Your total income next year (if you think it will be different) $ $ THANKS! This is all we need to know about you. NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994.
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Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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STEP 2: PERSON 2 Complete step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you do not file a tax return, remember to still add family members who live with you. 1. First name, Middle name, Last name, & Suffix 2. Relationship to you? 3. Date of birth (mm/dd/yyyy) 4. Sex Male Female 5. Social Security Number (SSN) - - We need this if you want health coverage and have an SSN. 6. Does PERSON 2 live at the same address as you? Yes No If no, list address: 7. Does PERSON 2 plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you do not file a federal income tax return.) YES. If yes, please answer questions a–c. NO. If no, skip to question c. a. Will PERSON 2 file jointly with a spouse? Yes No If yes, name of spouse: b. Will PERSON 2 claim any dependents on his or her tax return? Yes No If yes, list name(s) of dependents: c. Will PERSON 2 be claimed as a dependent on someone’s tax return? Yes No If yes, please list the name of the tax filer: How is PERSON 2 related to the tax filer?
8. Is PERSON 2 pregnant? Yes No a. If yes, how many babies are expected during this pregnancy? 9. Does PERSON 2 need health coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.) YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 5. Leave the rest of this page blank. 10. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? Yes No 11. Is PERSON 2 a U.S. citizen or U.S. national? Yes No 12. If PERSON 2 is not a U.S. citizen or U.S. national, do they have eligible immigration status? Yes. Fill in their document type and ID number below. a. Document type b. Document ID number c. Has PERSON 2 lived in the U.S. since 1996? Yes No d. Is PERSON 2, or their spouse or parent a veteran or an active- duty member in the U.S. military? Yes No 13. Does PERSON 2 want help paying for medical bills from the last 3 months? Yes No 14. Does PERSON 2 live with at least one child under the age of 19, and are they the main person taking care of this child? Yes No 15. Was PERSON 2 in foster care at age 18 or older? Yes No Please answer the following questions if PERSON 2 is 22 or younger: 16. Did PERSON 2 have insurance through a job and lose it within the past 3 months? Yes No a. If yes, end date: b. Reason the insurance ended: 17. Is PERSON 2 a full-time student? Yes No 18. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican Mexican American Chicano/a Puerto Rican Cuban Other 19. Race (OPTIONAL—check all that apply.) White American Indian or Filipino Vietnamese Guamanian or Chamorro Black or African Alaska Native Japanese Other Asian Samoan American Asian Indian Korean Native Hawaiian Other Pacific Islander Chinese
Other Now, tell us about any income from PERSON 2 on the back. NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994.
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STEP 2: PERSON 2 Current Job & Income Information Employed If you are currently employed, tell us about your income. Start with question 20. Not employed Skip to question 30. Self-employed Skip to question 29. CURRENT JOB 1: 20. Employer name and address 21. Employer phone number ( ) – 22. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly $ 23. Average hours worked each WEEK CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 24. Employer name and address 25. Employer phone number ( ) – 26. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly $ 27. Average hours worked each WEEK 28. In the past year, did PERSON 2: Change jobs Stop Working Start working fewer hours None of these 29. If self-employed, answer the following questions: a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? $ 30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: Income types including child support, veteran’s benefits, gifts, Supplemental Security Income (SSI), American Indian/Alaskan Payments, and educational assistance does not count for certain types of MO HealthNet Assistance. Only tell us about these types of income if you are applying for someone who is age 65 or older, or who has a disability. None
Alimony received $ How often? Unemployment $ How often? Net farming/fishing $ How often? Pensions $ How often? Net rental/royalty $ How often? Social Security $ How often? Other income Retirement accounts $ How often? Type: $ 31. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You should not include a cost that you already considered in your answer to net self-employment (question 29b). Alimony paid $ How often? Other deductions $ How often? Student loan interest $ How often? Type: 32. YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month. PERSON 2’s total income this year PERSON 2’s total income next year (if you think it will be different) $ $
THANKS! This is all we need to know about PERSON 2. If you have more than two people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete. NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994.
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STEP 3 American Indian or Alaska Native (AI/AN) family member(s) 1. Are you or is anyone in your family American Indian or Alaska Native? If No, skip to step 4. Yes. If yes, go to Appendix B. STEP 4 Your Family’s Health Coverage Answer these questions for anyone who needs health coverage. 1. Is anyone enrolled in health coverage now from the following? YES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have. NO. Medicaid CHIP Medicare TRICARE (Do not check if you have direct care or Line of Duty) VA Health care programs
Peace Corps Employer insurance Name of health insurance: Policy number: Is this COBRA coverage? Yes No Is this a retiree health plan? Yes No Other Name of health insurance: Policy number:
Is this a limited-benefit plan (like a school accident policy)? Yes No 2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s job, such as a parent or spouse. YES. If yes, you will need to complete and include Appendix A. Is this a state employee benefit plan? Yes No NO. If no, continue to Step 5. 3. Are you, any woman in your household, or any woman you are claiming as a tax dependent between the ages of 18 and 55 in need of family planning services? (Services include birth control, STD screenings, etc.) YES. NO. If yes, please list individuals: NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994.
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STEP 5 Read & sign this application. • I am signing this application under penalty of perjury which means I have provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false and or untrue information. • I know that I must tell the Family Support Division if anything changes (and is different than) what I wrote on this application. I can visit mydss.mo.gov or call 1-855-373-9994 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household. • I know that under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity or disability. I can file a complaint of discrimination by visiting http://dss.mo.gov/files/missouri-nondiscrimination-policy-statement.htm • I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not, is incarcerated. (name of person) We need this information to check your eligibility for help paying for health coverage if you choose to apply. We will check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information does not match, we may ask you to send us proof. Renewal of coverage in future years To make it easier to determine my eligibility for help paying for health coverage for future years, I agree to allow the Family Support Division to use income data, including information from tax returns. The Family Support Division will send me a notice, let me make any changes, and I can opt out at any time. Yes, renew my eligibility automatically for the next: 5 years (the maximum number of years allowed), or for a shorter number of years: 4 years 3 years 2 years 1 year Do not use information from tax returns to renew my coverage. If anyone on this application is eligible for MO HealthNet • I am giving to the Family Support Division our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to the Family Support Division rights to pursue and get medical support from a spouse or parent. • Does any child on this application have a parent living out of the home? Yes No • If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell Family Support Division and I may not have to cooperate. My right to appeal If I think the Family Support Division has made a mistake, I can appeal its decision. To appeal means to tell someone at the Family Support Division that I think the action is wrong, and ask for a fair review of the action. I know that I can find out how to appeal by calling the Contact Center at 1-855-373-9994. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me. Sign this application. The person who filled out step 1 should sign this application. If you are an authorized representative, you may sign here, as long as you have provided the information required in Appendix C. Signature Date (mm/dd/yyyy) STEP 6 Mail completed application. Mail your signed application to: PO BOX 1010 Union, MO 63084 If you want to register to vote, you can complete a voter registration form at http://www.sos.mo.gov/elections/goVoteMissouri/register.aspx NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994.
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APPENDIX A Health Coverage from Jobs You DO NOT need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage. Tell us about the job that offers coverage. Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need to include this page when you send in your application, not the Employer Coverage Tool.
EMPLOYEE Information 1. Employee name (First, Middle, Last) 2. Employee Social Security number - - EMPLOYER Information 3. Employer name 4. Employer Identification Number (EIN)
- 5. Employer address 6. Employer phone number ( ) – 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (If different from above) ( ) – 12. Email address 13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? Yes (Continue) 13a. If you are in a waiting or probationary period, when can you enroll in coverage? (mm/dd/yyyy) List the names of anyone else who is eligible for coverage from this job. Name: Name: Name: No (Stop here and go to Step 5 in the application) Tell us about the health plan offered by this employer. 14. Does the employer offer a health plan that meets the minimum value standard*? Yes No 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (do not include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs. a. How much would the employee have to pay in premium for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly 16. What change will the employer make for the new plan year (if known)? Employer will not offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $ b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly Date of change (mm/dd/yyyy): *An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994. MO 886-4537 (10-13)
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EMPLOYER COVERAGE TOOL
Use this tool to help answer questions in Appendix A about any employer health coverage that you are eligible for (even if it is from another person’s job, like a spouse). The information in the numbered boxes below match the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A. Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for each employer that offers health coverage.
EMPLOYEE Information The employee needs to fill out this section.
1. Employee name (First, Middle, Last) 2. Social Security Number
- -
EMPLOYER Information Ask the employer for this information.
3. Employer name 4. Employer Identification Number (EIN)
- 5. Employer address (the Family Support Division will send notices to this address) 6. Employer phone number ( ) – 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) ( ) – 12. Email address
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee) Tell us about the health plan offered by this employer. Does the employer offer a health plan that covers an employee’s spouse or dependent? Yes. Which people? Spouse Dependent(s) No (Go to question 14)
14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (do not include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you do not know, STOP and return form to employee. 16. What change will the employer make for the new plan year? Employer will not offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $ b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly
Date of change (mm/dd/yyyy):
*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994. MO 886-4537 (10-13)
IM-1SSL
Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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APPENDIX B American Indian or Alaska Native Family Member (AI/AN) Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Health Coverage & Help Paying Costs. Tell us about your American Indian or Alaska Native family member(s). American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following question to make sure your family gets the most help possible. NOTE: If you have more people to include, make a copy of this page and attach.
AI/AN PERSON 1 AI/AN PERSON 2 1. Name (First name, Middle name, Last name) First Middle First Middle Last Last 2. Member of a federally recognized tribe? Yes If yes, tribe name
No Yes If yes, tribe name
No 3. Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs?
Yes
No If no, is this person eligible to get services from Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs?
Yes No
Yes
No If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs?
Yes No 4. Certain money received may not be counted for MO HealthNet. List any income (amount and how often) reported on your application that includes money from these sources: • Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties • Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations) • Money from selling things that have cultural significance
$
How often?
$
How often? NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994. MO 886-4537 (10-13)
IM-1SSL
Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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APPENDIX C Assistance with Completing this Application You can choose an authorized representative. You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the Family Support Division. If you are a legally appointed representative for someone on this application, submit proof with the application. 1. Name of authorized representative (First name, Middle name, Last name) 2. Address 3. Apartment or suite number 4. City 5. State 6. ZIP code 7. Phone number ( ) – 8. Organization name 9. ID number (if applicable) By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency. 10. Your signature 11. Date (mm/dd/yyyy) For certified application counselors, navigators, agents, and brokers only. Complete this section if you are a certified application counselor, navigator, agent, or broker filling out this application for somebody else. 1. Application start date (mm/dd/yyyy) 2. First name, Middle name, Last name, & Suffix 3. Organization name 4. ID number (if applicable) NEED HELP WITH YOUR APPLICATION? Visit mydss.mo.gov or call us at 1-855-373-9994. Para obtener una copia de este formulario en Español, llame 1-855-373-9994. MO 886-4537 (10-13)
IM-1SSL
Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
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COORDINATION OF ELIGIBILITY AND ENROLLMENT
TRANSMITTAL NUMBER:
MO – 13-0024-MM2 STATE:
Missouri
Notwithstanding the final checked statement on page 2, the single state agency has not entered into an agreement with the Federally-facilitated Marketplace to date. The single state agency will make a good faith effort to enter into a memorandum of agreement with the Federally-facilitated Marketplace. At such time the agreement is signed, it will be incorporated by reference into this attachment
Transmittal Number: 13-0024-MM2 Approval Date: December 29, 2014 Effective Date: October 1, 2013
(spa)(mo-13-0026-mm3)(approval-document)Missouri Medicaid SPA MO-13-0026-MM3: Approval Document (approved March 25, 2014, effective January 1, 2014)#
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Table of Contents State/Territory Name: MO State Plan Amendment (SPA)#: 13-0026-MM3 This file contains the following documents in the order listed: 1. Approval Letter 2. Summary Form (with 179 – like data) 3. Superseding Pages Notice 4. Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106
Division of Medicaid and Children's Health Operations
March 26, 2014
Brian Kinkade, Interim Director Department of Social Services Broadway State Office Building PO Box 1527 Jefferson City, MO 65102
Dear Mr. Kinkade:
On December 31, 2013, the Centers for Medicare & Medicaid Services (CMS) received Missouri’s state plan amendment (SPA) transmittal #13-0026 MM3, which describes the financial eligibility methodologies that will apply to all Modified Adjusted Gross Income (MAGI)-based eligibility groups covered under Missouri’s Medicaid state plan. The MAGI financial methodologies set forth in 1902(e)(14) and 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI- based methods do not apply.
SPA 13-0026-MM3 was approved on March 25, 2014, with an effective date of January 1, 2014, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Missouri state plan.
If you have any questions regarding this amendment, please contact Deborah Read or Karen Hatcher at (816) 426-5925.
Sincerely,
/s/
James G. Scott
Associate Regional Administrator
for Medicaid and Children’s Health Operations
Enclosure
cc: Joe Parks, M.D.
Kimberly O’Hara Emily Rowe
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SUPERSEDING PAGES OF
STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: MO-13-0026 Missouri
PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:
S10 - MAGI Income Methodology
PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable): ‘
Notwithstanding any other provisions of the Missouri Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment MO-13-0026 will apply to all MAGI- based eligibility groups covered under Missouri’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.
Transmittal Number: MO-13-0026-MM3
Approval Date: March 25, 2014 Effective Date: January 1, 2014
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CMS Medicaid Eligibility
[OI FORMAN BCD
OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014
IMAGI-Based Income Methodologies S10
1902(e)(14) 42 CFR 435.603
ry The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603.
In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid 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 application of such methods results in a determination of ineligibility prior to such date.
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 as herself, plus one.
C 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 and family size for the remaining months of the current calendar year
In determining current monthly or projected annual household income, the state will use reasonable methods to: (7 Include a prorated portion of a reasonably predictable increase in future income and/or family size.
[X] Account for a reasonably predictable decrease in future income and/or family size.
Except as provided at 42 CFR 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.
In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d).
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.
@ Yes CNo
Transmittal Number: MO-13-0026-MM3 Approval Date: March 25, 2014 Effective Date: January 1, 2014 Page 1 of 2
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CCmMsS Medicaid Eligibility
[m] The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is:
@ Age 19
C Age 19, or in the case of full-time students, age 21
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 40 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.
Transmittal Number: MO-13-0026-MM3 Approval Date: March 25, 2014 Effective Date: January 1, 2014 Page 2 of 2
(spa)(mo-14-0012-mm7)(approval-document)Missouri Medicaid SPA MO-14-0012-MM7: Approval Document (approved November 3, 2014, effective January 1, 2014)#
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Table of Contents
State/Territory Name: MO State Plan Amendment (SPA) #: 14-0012-MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106
Division of Medicaid and Children's Health Operations
November 4, 2014
Brian Kinkade, Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, Missouri 65102
Dear Mr. Kinkade:
On March 31, 2014, the Centers for Medicare & Medicaid Services (CMS) received Missouri’s State Plan Amendment (SPA) transmittal #14-0012-MM7, which describes the Modified Adjusted Gross Income (MAGI)-based hospital presumptive eligibility criteria covered under Missouri’s Medicaid State Plan. The MAGI presumptive eligibility as set forth in 42 CFR § 435.1110 allows states to provide Medicaid services to children under 19 years of age, during period of presumptive eligibility, prior to formal determination.
SPA 14-0012-MM7 was approved on November 3, 2014, with an effective date of January 1, 2014, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Missouri State Plan.
If you have any questions regarding this amendment, please contact Deborah Read or Karen Hatcher at (816) 426-5925.
Sincerely,
James G. Scott
Associate Regional Administrator
for Medicaid and Children’s Health Operations
Enclosure
cc: Joe Parks, M.D. Debbie Melller
Kim O’Hara
//s//
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State/Territory name: Missouri Submitted By: Kimberly O'Hara Last Revision Date: Oct 29, 2014 Submit Date: Mar 31, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-0012 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.1110 Federal Budget Impact Federal Fiscal Year Amount First Year 2013 $ 0.00 Second Year 2014 $ 0.00 Subject of Amendment Presumptive eligiblity determinations by qualified entities-hospitals Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 10/30/2014
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Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ✔ A qualified hospital is a hospital that: ■ Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. ■ Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. ■ Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes No The eligibility groups or populations for which hospitals determine eligibility presumptively are: ■ Pregnant Women ■ Infants and Children under Age 19 ■ Parents and Other Caretaker Relatives ■ Adult Group, if covered by the state ■ Individuals above 133% FPL under Age 65, if covered by the state ■ Individuals Eligible for Family Planning Services, if covered by the state ■ Former Foster Care Children ■ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state ■ Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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Page 2 of 3 Medicaid Eligibility Yes No Select one or both: The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. Description of standards: 95% of PE applications must result in a regular application. (this standard will be applied 12 months from the date of the hospital’s election to determine PE. Hospitals failing to meet this standard after the 12 month exemption period must submit a corrective action plan to be monitored quarterly. If still not meeting expectations established in corrective action plan after one year, the hospital will be disqualified from determining presumptive eligibility for 3 yrs) The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. Description of standards: 90% accuracy standard. (this standard will be applied 12 months from the date of the hospital’s election to determine PE. Hospitals failing to meet this standard after the 12 month exemption period must submit a corrective action plan to be monitored quarterly. If still not meeting expectations established in corrective action plan after one year, the hospital will be disqualified from determining presumptive eligibility for 3 yrs) The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: Name of limitation Description + Limitation for Pregnancy No more than one period per pregnancy x + Limitation for all other programs No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. x The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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Page 3 of 3 Medicaid Eligibility The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. The presumptive eligibility determination is based on the following factors: ■ The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) ■ Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included. ✔ An attachment is submitted. 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 40 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. Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 1 Missouri Department of Social Services Presumptive Eligibility (PE) Program Training for Qualified Entities 1 (v5) June 4, 2014 Contents In this training, the following will be covered: Overview of the Presumptive Eligibility (PE) Program How Entities can participate in PE Who is eligible to enroll in MO HealthNet through PE? What are the benefits? Determining Eligibility Terms and Definitions Eligibility Requirements Household Composition Income Determination Submitting applications for PE individual(s) 2 (v5) June 4, 2014 Presumptive Eligibility Overview 3 (v5) June 4, 2014 Presumptive Eligibility (PE) Overview Presumptive Eligibility allows individuals whose family meets certain requirements to receive MO HealthNet benefits for a period of time. The Affordable Care Act (ACA) expanded Presumptive Eligibility (PE). Since 1990, PE has been available for pregnant women. This group is still eligible. Since 1997, PE has been available for children. This group is still eligible. Since 2001, PE has been available for breast and cervical cancer treatment. This group is still eligible. ACA established PE criteria for parents, caretakers, and former foster children age 19-26. 4 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 2 PE Overview Following completion of training and signing an agreement form, Qualified entities may determine PE eligibility for certain individuals who are likely to be eligible for regular MO HealthNet. Assist PE applicants to apply for regular MO HealthNet at mydss.mo.gov, or by completing the Missouri Single Streamlined Application (IM-1SSL) Eligibility under PE is temporary but allows immediate access to coverage for eligible individuals. 5 (v5) June 4, 2014 PE Overview Ensures hospitals will be reimbursed for services provided. PE is not about short-term coverage; it provides an opportunity to get individuals connected to longer-term coverage options. Applying for regular MO HealthNet at mydss.mo.gov is the fastest path to full coverage. 6 (v5) June 4, 2014 How Entities Can Participate in PE 7 (v5) June 4, 2014 How Entities Can Participate in PE Participation in PE is optional, but states must provide a mechanism for an entity to become qualified to conduct PE To make PE determinations, an entity must: Participate in the MO HealthNet program Notify Missouri Department of Social Services, Family Support Division, IM Program and Policy Unit at COLE.MHNPolicy@dss.mo.gov or PO BOX 2320 Jefferson City, MO 65102. Agree to make PE determinations consistent with policies and procedures. 8 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 3 PE Qualified Entity Responsibilities and Agreement page 1 9 (v5) June 4, 2014 PE Qualified Entity Responsibilities and Agreement page 2 10 (v5) June 4, 2014 Hospital Staff Eligible to Make HPE Determinations Once an entity has been qualified: An employee who is properly trained and certified can make PE determinations • Including employees in hospital-owned physician practices or clinics, and those in off-site locations Participating entities may not delegate PE determinations to non-hospital staff • Third party vendors or contractors may not make PE determinations Participating entities must meet performance standards set by the state and maintain adequate status as a qualified PE Provider 11 (v5) June 4, 2014 Entity Staff Training and Certification IM Training Unit of the Family Support Division (FSD) has developed training for Qualified Entity (QE) Staff The QE may request and receive training from staff at the local FSD office The initial training for QE staff is provided by FSD Viewing this presentation is part of the initial training 12 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 4 PE Performance Standards To remain a PE provider, a provider must meet performance standards PE provider must: Check for existing MO HealthNet coverage prior to completing PE determination. Note: Extended Women’s Health Services (EWHS – ME code 80) and Uninsured Women’s Health Services (UWHS – ME code 89) are not considered MO HealthNet programs for determining PE. Expectation: Correct determination on 98% or more of applications Check for receipt of PE within past 12 months, or current pregnancy (TEMP). Expectation: Correct on 98% or more of applications 13 (v5) June 4, 2014 PE Performance Standards Determine PE accurately on 95% or more of applications Assist applicants in completing and submitting MO HealthNet application (IM-1SSL) Expectation: 90% of these application should be received prior to end date of PE period IM-1SSL applications received prior to end of PE period will be used to determine ongoing MO HealthNet eligibility. Expectation: 95% of these applications should approved for ongoing coverage Note: Ongoing application rejected because the applicant did not meet citizenship/qualified alien criteria or did not provide verification will not be used in this measurement. 14 (v5) June 4, 2014 PE Performance Standards The state has the authority to take corrective action against Qualified Entities, including termination from the PE program, if the QE does not follow state policies or does not meet established standards We will talk about corrective action plans (CAP) later in this training 15 (v5) June 4, 2014 Who is Eligible to Enroll in MO HealthNet through PE? What are the Benefits? 16 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 5 Populations Eligible for MO HealthNet via PE Determinations Pregnant Women, Infants and Children under age 19, Parents/Caretakers of children age 0-18, Former Missouri Foster Care Child through age 26 and; Breast and Cervical Cancer Treatment (BCCT) 17 (v5) June 4, 2014 PE for Pregnant Women Qualified Entities can determine PE for pregnant women. Limited to one PE coverage period per pregnancy Self-Attestation of eligibility requirements PE application is taken on the PE-1SSL Children born to PE only mother, are not eligible for Newborn coverage; unless, the mother is found eligible for retroactive regular MO HealthNet coverage. 18 (v5) June 4, 2014 PE for Children – Parents – Caretakers and Former Foster Children Limited to one PE coverage period per year, per person Self-Attestation of eligibility requirements PE application is taken for the individual(s) on the PE-1SSL Only hospitals may determine PE for former foster children and parents/caretakers 19 (v5) June 4, 2014 Benefits Pregnant women determined eligible for PE, receive ambulatory prenatal care (excludes labor and delivery). Children/Parents and Caretakers/Former Foster Children/BCCT patients determined eligible under PE, receive the same coverage as those provided under the MO HealthNet group for which the individual is determined presumptively eligible. 20 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 6 Benefits Coverage, under PE, begins the day the QP makes the PE determination. PE coverage ends on the earliest of either: The date the eligibility determination for full MO HealthNet is made by FSD Example: PE determined 2/8/2014. Eligibility period 2/8/14 – 3/31/14. FSD determines eligibility for regular MO HealthNet coverage on 2/19/14. PE ends the date of the approval or denial for MO HealthNet coverage 2/19/14. The last day of the following month in which the QP made the PE determination (if a full MO HealthNet application is not filed by the individual). Benefits are received through fee-for-service. No appeal rights for PE determination. 21 (v5) June 4, 2014 Determining Presumptive Eligibility 22 (v5) June 4, 2014 Determining PE Eligibility Terms and Definitions With every program there are new terms and definitions to learn. Use the chart as a reference until you become familiar with the terms and definitions. Let’s look at determining PE. 23 (v5) June 4, 2014 Determining Presumptive Eligibility First, check eMOMED to see if the patient is already receiving MO HealthNet coverage. If not, begin PE determination process by completing and/or assist in completing the Application for Presumptive Eligibility (PE- 1SSL) 24 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 7 Determining Presumptive Eligibility Eligibility Requirements Individual applicant must: Fall into one of the following MO HealthNet groups Pregnant Women, Infants and Children under age 19, Parents/caretakers of children ages 0-18, Former Missouri foster care child(ren) ages 19 through 26 or; Breast and Cervical Cancer Treatment (BCCT) Must not be receiving MO HealthNet under any other category (excluding UWHS or EWHS) Have income below the applicable income guideline for household size. Exceptions: BCCT and Foster Care PE do not have income guidelines. 25 (v5) June 4, 2014 Determining Presumptive Eligibility Eligibility Requirements –Pregnant Women Pregnant Women must also meet the following requirements: Resident of Missouri Household income must be at or below 196% of FPL Pregnancy and number of children expected Citizenship or qualified immigrant – self attestation, not verified 26 (v5) June 4, 2014 Determining Presumptive Eligibility Eligibility Requirements – Infants and Children Infants and children under 19 must meet the following requirements: Household income must be at or below 196% of FPL for children under age 1 and 150% of FPL for children ages 1 thru 18. Resident of Missouri Citizenship or qualified immigrant – self attestation, not verified 27 (v5) June 4, 2014 Determining Presumptive Eligibility Eligibility Requirements – Parents/Caretakers Parents and caretakers of children between 0- 18 must meet the following requirements: Resident of Missouri Citizenship or qualified immigrant – self attestation, not verified Must meet the MO HealthNet for Families (MAF) relationship criteria Parent , certain specified relatives, and spouse of a relative or legal guardian Must meet MO HealthNet for Families income guidelines Only qualified hospitals may determine PE for parents/caretakers 28 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 8 Determining Presumptive Eligibility Eligibility Requirements – Former Missouri Foster Child Former Missouri Foster Children ages 19-26 must be: In Missouri foster care on or 30 days prior to their 18th birthday Qualified Hospitals are the only providers who can determine eligibility for this category No income guidelines for former foster child(ren) Citizenship or qualified immigrant – self attestation, not verified 29 (v5) June 4, 2014 Determining Presumptive Eligibility Eligibility Requirements – Breast and Cervical Cancer Treatment BCCT applicants must: Be uninsured Be under age 65 Be a U.S. Citizen or qualified immigrant Meet screening criteria and need treatment for breast and cervical cancer No income guidelines for BCCT Determinations for BCCT made by Show ME Healthy Women (SMHW) providers who have an agreement with Department of Health and Senior Services Only hospitals who are SMHW providers may make BCCT PE determination 30 (v5) June 4, 2014 Determining Presumptive Eligibility Eligibility Requirements All PE is based on information as declared by applicant (self-attestation). Physical verifications cannot be required, including proof of pregnancy, citizenship, and income. 31 (v5) June 4, 2014 Determining Presumptive Eligibility We discussed the eligibility requirements an applicant/household must meet for each PE group. Eligibility requirements included the household’s income is at or below the income guideline. Exceptions are BCCT and former foster child(ren) Let’s look at how household’s are determined 32 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 9 Determining Presumptive Eligibility MAGI Modified Adjusted Gross Income = “MAGI” Method of determining income used for eligibility Based on federal tax rules MO uses current monthly income 5% income disregard of the applicable income guideline refer to the included PE-1 Worksheet on slides 59-67. MAGI Households are based upon federal tax filing rules 33 (v5) June 4, 2014 Determining Presumptive Eligibility Identifying PE Household Identifying a PE Household Trained QE staff will use applicant’s declaration on the PE-1SSL to determine a patient’s household size. Household is determined by the relationship of the applicant to all other members of the household. 34 (v5) June 4, 2014 Determining Presumptive Eligibility Identifying PE Household PE-1SSL 35 (v5) June 4, 2014 Determining Presumptive Eligibility Identifying PE Household PE-1SSL 36 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 10 Determining Presumptive Eligibility Identifying PE Household PE-1SSL 37 (v5) June 4, 2014 Determining Presumptive Eligibility Identifying PE Household PE-1SSL 38 (v5) June 4, 2014 Determining Presumptive Eligibility Identifying PE Household Special Circumstances: For pregnant women, the unborn child(ren) is included in the total number of household members. For TEMP, if the father of the unborn child is not the spouse to or does not file taxes with the pregnant woman, he is not included in the TEMP household. If there is a stepparent in the home, the stepparent is included in the PE household. 39 (v5) June 4, 2014 Tax Filer Determining Presumptive Eligibility MAGI Household – Tax Filing Statuses Tax Dependent Non-Filer Child An individual who expects or plans to file a tax return for the taxable year in which coverage is being requested. An individual who expects to be claimed as a tax dependent by another taxpayer for the taxable year in which coverage is being requested. An individual who does not expect nor plans to file a tax return and does not expect to be claimed as a tax dependent for the taxable year in which coverage is being requested. Individuals between the ages of 0 and 19 40 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 11 Determining Presumptive Eligibility MAGI Household – Tax Filer If individual states s/he is planning to file taxes, household consists of: Individual Spouse (if living with the tax filer) All individuals claimed as tax dependents of the tax filer 41 (v5) June 4, 2014 Determining Presumptive Eligibility MAGI Household – Tax Dependent If individual declares to be a tax dependent, the household consists of: Individual Tax Filer claiming individual Tax Filer’s spouse if living with the tax filer All dependents claimed by tax filer Tax Dependent’s spouse if living with tax dependent 42 (v5) June 4, 2014 Determining Presumptive Eligibility MAGI Household – Exceptions Exceptions to the Rules: Use non-filer rules when: A tax dependent is claimed by someone other than a spouse or parent A tax dependent (under age 19) who lives with both parents, but whose parents will not file jointly and only one parent claims child A tax dependent is claimed by a non-custodial parent 43 (v5) June 4, 2014 Determining Presumptive Eligibility PE Household Basic Rules to PE Non-Filer Households Applicant is a person over 18, household includes: Applicant Spouse if living with applicant Applicant’s child(ren) under age 19 who live in the home Applicant is a person under age 18, household includes: Applicant Parent(s) (biological, adopted or stepparent(s)) living in the home Sibling(s) (biological, adopted or stepsibling(s)) under age 19, living in the home 44 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 12 Determining Presumptive Eligibility MAGI Household – Examples Two resources have been created to help determine MAGI households. Step by Step Guide Flow Chart Review the following household examples. Use the linear or flow chart to help identify the MAGI household. Let’s look at some examples 45 (v5) June 4, 2014 Determining Presumptive Eligibility PE Household – Examples Household: Lela – mother, age 39 David – father, age 41 Ashley – Lela’s daughter, age 12 Eric – Lela and David’s son, age 7 Lela is applying for PE for Ashley. Ashley is a resident of Missouri and eMOMED shows Ashley has not received PE in the past 12 months. Lela claims Ashley as a tax dependent for federal tax filing. The PE household for Ashley’s determination is: • Ashley • Lela • David • Eric 46 (v5) June 4, 2014 Determining Presumptive Eligibility PE Household – Examples Household: Nadia – applicant, age 17, pregnant Megan – Nadia’s mother, age 41 Lester – Nadia’s father, age 42 Tonya – Nadia’s sister, age 14 Nadia is applying for PE for herself. Nadia states she is a resident of Missouri and eMOMED shows Nadia has not had PE coverage during the current pregnancy. Lester and Megan, Nadia’s parents, claim both Nadia and Tonya as federal tax dependents. The PE household for Nadia’s determination is: • Nadia • Megan • Lester • Tonya • Unborn child 47 (v5) June 4, 2014 Determining Presumptive Eligibility PE Household – Examples Household: Gayle – applicant, age 27 Tyler – Gayle’s son, age 5 Gayle is applying for PE for herself. Gayle states she is a resident of Missouri and eMOMED shows Gayle has not had PE coverage in the past 12 months. Gayle is not filing federal taxes for this year. The PE household for Gayle’s determination is: • Gayle • Tyler 48 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 13 Determining Presumptive Eligibility PE Household – Examples Household: Faith – applicant, age 27 pregnant Randy – Faith’s boyfriend and unborn child’s father, age 29 Hannah – Faith’s daughter, age 3 Faith is applying for PE for herself. Faith states she is a resident of Missouri and eMOMED shows Faith has not had PE coverage during the current pregnancy. Faith is filing federal taxes for this year and claims Hannah as a tax dependent. The PE household for Faith’s determination is: • Faith • Hannah • Unborn child 49 (v5) June 4, 2014 Determining Presumptive Eligibility PE Household – Examples Household: Gena – applicant, age 43 Travis – Gena’s husband, age 44 Tara – Gena’s daughter, age 17 Gavin – Gena’s son, age 14 Gena is applying for BCCT- PE for herself. She has been diagnosed with cervical cancer by a Show Me Healthy Women (SMHW) provider and is in need of treatment. Gena states she is a resident of Missouri and eMOMED shows Gena has not had PE coverage during the past 12 months. Gena is filing joint federal taxes with Travis for this year. They claim both children as tax dependents. The PE household for Gena’s determination is: • Gena NOTE: Only the woman is counted in the household to determine PE - BCCT 50 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating Income We determined PE household composition Now, let’s look at how to calculate household income. General rule is the same as tax definition: • If income is taxable it is counted • If income is non taxable it is not counted Also, if an individual is part of the PE household, his/her taxable income counts. 51 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI –Exceptions Exceptions: 1. If the individual is under 19 and is expected to be required to file taxes, his/her income counts. If not required to file taxes, income does not count. 2. If the individual is expected to be claimed as a tax dependent of another household member and s/he is expected to be required to file his/her own taxes, his/her income counts. If not required to file taxes, income does not count. Note: Federal tax laws mandate persons who earn at least the threshold amount or great, must file taxes. These threshold amounts change annually. The current 2014 tax thresholds are: Individuals earning more than $10,150 per year; Couples filing jointly earning at least $20,300 per year; Individuals filing as a head of household earning at least $13,050 per year. 52 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 14 Determining Presumptive Eligibility Calculating MAGI Countable income includes: Taxable Wages/Salary (before taxes are taken out) Pretax contributions to dependent care accounts, health insurance premiums, flexible spending accounts, retirement accounts and commuter expenses are NOT included as income Self-Employment Profit once expenses are paid Social Security Benefits Unemployment Benefits Alimony Received Most Retirement Benefits Interest – including tax-exempt interest Net Capital Gains Most investment income Rental or royalty income Other taxable income Lump sum is only counted in the month received Income of child under 19 who is required to file taxes, as his/her income equals or exceed the federal tax filing threshold 53 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI Non-Countable income includes: Temporary Assistance and other government cash assistance Supplemental Security Income (SSI) Child Support Received Veteran’s Benefits Workers Compensation Payments Proceeds from life insurance, accident insurance, or health insurance Federal tax credits Scholarships, awards, or fellowship grants used for education, but not living expenses American Indian/Alaskan Native income derived from distribution, payments, ownership interests, and real property usage rights Income of a child under age 19 who is not required to file taxes, as his/her income is less than the federal tax filing threshold 54 (v5) June 4, 2014 Determining Presumptive Eligibility MAGI – Tax Adjustments MAGI is determined using Federal tax rules. These rules include the use of tax adjustments or deductions. Most common deductions are: Certain self-employment business expenses Alimony paid Health savings accounts Student loan interest paid Income for PE determinations will be based on customer’s attested amount. 55 (v5) June 4, 2014 Determining Presumptive Eligibility MAGI – Tax Adjustments These are the eligible tax deductions under MAGI rules. They can be used to calculate the applicant’s household income. If household does not have information regarding deductions, the PE determination is made without them. 56 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 15 Determining Presumptive Eligibility Determining MAGI Basic steps to determine MAGI eligibility Determine household’s monthly income - Household’s monthly tax deductions = Net Income Compare to maximum income guideline 57 (v5) June 4, 2014 Determining Presumptive Eligibility Determining MAGI Presumptive Eligibility Determination form (PE-1Worksheet) is used in determining eligibility for the PE programs Section A is used to determine prior PE coverage Section B is used to determine residency Section Section C is used to determine income eligibility Section D is used to identify the outcome Section E is used to identify eligibility/non-eligibility and reason Let’s look at PE-1Worksheet. 58 (v5) June 4, 2014 Determining Presumptive Eligibility Determining MAGI PE-1Worksheet 59 (v5) June 4, 2014 Determining Presumptive Eligibility Determining MAGI PE-1Worksheet 60 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 16 Determining Presumptive Eligibility Determining MAGI PE-1Worksheet 61 (v5) June 4, 2014 Determining Presumptive Eligibility Determining MAGI PE-1Worksheet (v4) May 1, 2014 62 F. Is the STANDARD more than TOTAL MONTHLY INCOME? (Is line 6 greater than line 7?) IF YES, INDIVIDUAL(S) ARE ELIGIBLE FOR PRESUMPTIVE ELIGIBILITY. YES NO G. ELIGIBLE INELIGIBLE Reason ineligible: Has active MO HealthNet Received Presumptive Eligibility during the last 12 months Not a Missouri Resident Not a U.S. Citizen or qualified and eligible immigrant Received TEMP during current pregnancy Excessive income QE Name: QE Number: Signature Date Applicant Name: Applicant Signature Date MO 886-4051 (03-14) PE-1WORKSHEET (06/2014) Determining Presumptive Eligibility Determining MAGI PE-1Worksheet (v4) May 1, 2014 63 INCOME STANDARDS after April 1, 2014 through March 31, 2015 (the number provided is the FPL for household with a 5% income disregard included) CHILDREN AGES 1 THROUGH AGE 18 (until the day before their 19th birthday) ASST. GROUP SIZE GROSS MO. INCOME ASST. GROUP SIZE GROSS MO. INCOME 1 $1532 5 $3663 2 $2065 6 $4196 3 $2597 7 $4729 4 $3130 8 $5262 Determining Presumptive Eligibility Determining MAGI PE-1Worksheet (v4) May 1, 2014 64 PREGNANT WOMEN AND CHILDREN UNDER AGE 1 ASST. GROUP SIZE GROSS MO. INCOME ASST. GROUP SIZE GROSS MO. INCOME 1 $2001 5 $4559 2 $2698 6 $5483 3 $3394 7 $6179 4 $4090 8 $6875 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 17 Determining Presumptive Eligibility Determining MAGI PE-1Worksheet (v4) May 1, 2014 65 INCOME STANDARDS FOR PARENTS OR CARETAKERS OF CHILDREN UNDER AGE 19 (this number does not adjust annually) ASST. GROUP SIZE GROSS MO. INCOME ASST. GROUP SIZE GROSS MO. INCOME 1 $148 5 $420 2 $253 6 $467 3 $316 7 $515 4 $371 8 $559 Determining Presumptive Eligibility Determining MAGI PE-1Worksheet (v4) May 1, 2014 66 ELIGIBLE, QUALIFIED NON-CITIZENS (applicant statement is accepted) NON-CITIZENS MUST MEET: ONE CRITERIA FROM SECTION A AND ONE CRITERIA FROM SECTION B, OR ONE CRITERIA FROM SECTION C A. ELIGIBLE B. QUALIFIED Lawful permanent resident Paroled 212(d)(5) of INA Granted conditional entry Battered Non-citizen Resided in the US with a qualified status for five years Non-citizens with a U.S. Military Connection: o Honorably discharged veteran with at least 2 years of active duty service o Military personnel on active duty (not active for training only.) o Spouse, or dependent child of a veteran or active duty military Non-married surviving spouse of a veteran Determining Presumptive Eligibility Determining MAGI PE-1Worksheet (v4) May 1, 2014 67 C. ELIGIBLE AND QUALIFIED Refugee (207 INA) Asylee (208 INA) Amerasian Trafficking Victim Cuban/Haitian Non-citizen Deportation withheld 243(h) of (INA) or 241(b)(3) American Indian born in Canada, if s/he is at least ½ American Indian blood Determining Presumptive Eligibility Calculating MAGI - Examples Let’s look at completing the PE-1Worksheet including how MAGI is calculated. We will work with the same households we looked at earlier in the training. Lela Nadia Gayle Faith Gena 68 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 18 Determining Presumptive Eligibility Calculating MAGI - Examples Household: Lela – mother, age 39 David – father, age 41 Ashley – Lela’s daughter, age 12 Eric – Lela and David’s son, age 7 Lela is applying for PE for Ashley. We determined Ashley’s household is Ashley, Lela, David, and Eric. Ashley is a resident of Missouri and has not received PE in the past 12 months. Lela and David claim both Ashley and Eric as a tax dependents for this year’s federal tax filing. Household income: Lela earns $1,000.00 monthly David earns $500.00 weekly Ashley receives child support - $150.00 monthly 69 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •Ashley has not received PE in the last 12 months •Ashley is a resident of Missouri •Ashley qualifies for PE at this point •Let’s look at her income eligibility 70 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •Lela earns $1,000.00 monthly •David earns $500.00 weekly x 4.333 = $2166.50 •Ashley receives child support which is excluded •No tax deductions claimed •Total monthly income is $3166.50 ($1,000.00+$2166.50) •Maximum income for 4 person household is $2982.00 •Ashley does not meet the income guidelines •Add 5% (149.10) to the maximum income $2982.00 + $149.10= $3131.00 – Ashley continues to be ineligible 71 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •Ashley’s household income is in excess of the maximum •Ashley is not eligible for PE •Ineligibility is notated at the bottom of the PE-1Worksheet •The PE-1Worksheet is signed by the QE and Applicant 72 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 19 Determining Presumptive Eligibility Calculating MAGI - Examples Household: Nadia – applicant, age 17, pregnant, full time student and works part time. Megan – Nadia’s mother, age 41 Lester – Nadia’s father, age 42 Tonya – Nadia’s sister, age 14 Nadia is applying for PE for herself. We determined Nadia’s PE household is: Nadia, Megan, Lester, Tonya and unborn child. Megan and Lester claim Nadia and Tonya as tax dependents for federal tax filing. Nadia is a resident of Missouri and has not received PE during this pregnancy. Household income: Nadia earns $281 monthly Megan earns $1800 monthly Lester earns $2600 monthly 73 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •Nadia has not received PE during this pregnancy •Nadia is a resident of Missouri •Nadia qualifies for PE at this point •Let’s look at her income eligibility 74 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •Megan earns $1,800.00 monthly •Lester earns $2600.00 monthly •Nadia earns $281.00 monthly •No tax deductions claimed •Total monthly income is $4400.00 ($1800+$2600=$4400.00) •Nadia’s income is excluded as she is not required to file taxes •Maximum income for 5 person MPW household is $4559.00 •Nadia is eligible for PE coverage 75 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •Nadia is eligible for PE •The PE-1Worksheet is signed by the QE and Applicant •PE-2 and QP-2 are completed for Nadia’s eligibility 76 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 20 Determining Presumptive Eligibility Determining Eligibility - Exercise 77 (v5) June 4, 2014 Determining Presumptive Eligibility Determining Eligibility - Exercise Nadia Walker Today Last of month, next month 06/18/1996 XXXXXXXX Hospital A Cindy Giles 78 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples Household: Gayle – applicant, age 27 Tyler – Gayle’s son, age 5 Gayle is applying for PE for herself. We determined Gayle’s PE household is Gayle and Tyler. Gayle is a resident of Missouri and has not received PE in the past 12 months. Gayle is not planning to file federal taxes for this year. Household income: Tyler receives $750 monthly child support 79 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •Gayle has not received PE in the past 12 months •Gayle is a resident of Missouri •Gayle qualifies for PE at this point •Only hospitals may determine PE eligibility for parents/caretakers •Let’s look at her income eligibility 80 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 21 Determining Presumptive Eligibility Calculating MAGI - Examples •Tyler’s child support income is excluded •Gayle is eligible for PE based on income 81 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •The PE-1Worksheet is signed by the QE and Applicant •PE-2 is completed for Gayle’s eligibility 82 (v5) June 4, 2014 Determining Presumptive Eligibility Determining Eligibility - Exercise 83 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples Household: Faith – applicant, age 27 pregnant Randy – Faith’s boyfriend and unborn child’s father, age 29 Hannah – Faith’s daughter, age 3 Faith is applying for PE for herself. The PE household for Faith’s determination is Faith, Hannah, and unborn child. Faith is a resident of Missouri and has not received PE for the current pregnancy. Faith is filing federal taxes this year and claims Hannah as her tax dependent. Household income: Faith - $450.00 weekly income Randy - $900.00 every two weeks Hannah - $350.00 monthly child support 84 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 22 Determining Presumptive Eligibility Calculating MAGI - Examples •Faith has not received PE during this current pregnancy •Faith is a resident of Missouri •Faith qualifies for PE at this point •Let’s look at her income eligibility 85 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •Household monthly income is $1949.85 ($450.x4.333 =$1949.85) •Hannah’s child support income is excluded •Randy is not part of the PE household and therefore, his income is excluded. •Maximum income limit for 3 persons (Faith, Hannah and unborn child) for PE for Pregnant Women is $3233.00 86 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples •The PE-1Worksheet is signed by the QE and Applicant •PE-2 and the QP-2 is completed for Faith’s eligibility 87 (v5) June 4, 2014 Determining Presumptive Eligibility Determining Eligibility - Exercise 88 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 23 Determining Presumptive Eligibility Determining Eligibility – Exercise – QP-2 Dalton, Faith Today Last day of month next month 3/10/1987 XXXXXXX X Hospital A Wendy Palmer 89 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples 90 (v5) June 4, 2014 Household: Gena – applicant, age 43 Travis – Gena’s husband, age 44 Tara – Gena’s daughter, age 17 Gavin – Gena’s son, age 14 Gena is applying for PE -BCCT for herself. She has been diagnosed with cervical cancer by a Show Me Healthy Women (SMHW) provider. Gena states she is a resident of Missouri and eMOMED shows Gena has not had PE coverage in the last 12 months. Gena is filing joint federal taxes with Travis for this year. They claim both children as tax dependents. Household Income: Gena - $1500.00 monthly Travis - $1600.00 monthly Gena is eligible for PE-BCCT NOTE: For PE-BCCT income is only used to determine if the woman is eligible to receive the necessary screening through SMWH providers, not PE –BCCT determinations. Determining Presumptive Eligibility Calculating MAGI - Examples 91 (v5) June 4, 2014 Determining Presumptive Eligibility Calculating MAGI - Examples 92 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 24 Determining Presumptive Eligibility Determining Eligibility We have: Reviewed the PE-1SSL Determined household composition Determined household income Reviewed and completed the PE-1Worksheet Reviewed the approval notice PE-2 MO HealthNet Presumptive Eligibility Authorization It’s time for you complete the process of determining eligibility for PE. 93 (v5) June 4, 2014 Determining Presumptive Eligibility Determining Eligibility - Exercise Case Scenarios for practice Paulette Allen Mary Latner George Andrews Joan Calvert Amy Wright 94 (v5) June 4, 2014 Determining Presumptive Eligibility Determining Eligibility You have had a chance to determine PE eligibility on your own, what happens after eligibility is determined? If individual meets all requirements: Provide the individual/family a completed Presumptive Eligibility Authorization (PE-2). The PE-2 is used to obtain covered medical services for the identified individual(s) from an enrolled MO HealthNet fee-for- service provider. Notify the individual/family’s PE coverage period Assist the individual/parent/caretaker in completing the IM-1SSL and advise him/her that the application is sent to the local FSD office for a formal determination of on-going eligibility for MO HealthNet coverage. If eligible for on-going coverage, a white, plastic “MO HealthNet” card is sent to individual(s). 95 (v5) June 4, 2014 Determining Presumptive Eligibility Determining Eligibility What happens after eligibility is determined? If individual does not meets all requirements: Provide the individual/family a copy of the PE-1Worksheet, including the reason the individual(s) is ineligible for presumptive MO HealthNet. Assist the individual/parent/caretaker in completing the IM - 1SSL and advise him/her that the application is sent to the local FSD office for a formal determination of on-going eligibility for MO HealthNet coverage. Next Step – submit application for PE individual(s) 96 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 25 Submit Applications for PE Individual(s) Once a determination has been made: If eligible Send the following forms to local FSD office within 5 working days of the PE determination Presumptive Eligibility Application form (PE-1SSL) – For identification purposes, note on the application form the name of the Qualified Entity submitting the form. Copy of Presumptive Eligibility Determination (PE-1Worksheet) Copy of the MO HealthNet Presumptive Eligibility Authorization form (PE-2) MO HealthNet Application form (IM-1SSL) Maintain copies of all forms used in determination process If ineligible Send the IM-1SSL, and PE-1Worksheet to the same or next day so it is received by FSD within five (5) working days of the determination Maintain copies of all forms used in determination process 97 (v5) June 4, 2014 Submit Applications for PE Individual(s) Performance Standards We discussed earlier in this training QE expectations and performance standards 98% or more correctness of checking existing MO HealthNet coverage 98% or more correctness of receipt of PE within past 12 months and current pregnancy for TEMP 95% or more accurate PE determinations 90% or more IM-1SSL applications received by end of PE period 95% or more ongoing MO HealthNet applications are approved What happens if performance standard not met? 98 (v5) June 4, 2014 Submit Applications for PE Individual(s) Performance Standards If performance standards are not met QE receives notification from the Division QE submits a corrective action plan (CAP) for review by Division Upon approval of CAP, QE must implement and satisfactorily complete the CAP within time frames If QE does not submit a CAP accepted by Division or again fails to meet performance standard, QE may be disqualified as a PE qualified entity for the period of 1 year If QE is disqualified, QE receives notice 30 days prior to disqualification QE has 10 calendar days to submit a request for reconsideration to the department director Reconsideration is within the discretion of the department director 99 (v5) June 4, 2014 PE Determination Checklist 1. Verify applicant is not currently enrolled in MO HealthNet by checking eMOMED 2. Verify through eMOMED that applicant has not received PE in previous year or during current pregnancy 3. Identify the coverage group (pregnant women, child under 19, parents/caretaker relative, former foster care children) the applicant may be PE for 4. Determine MAGI household 5. Calculate the applicant’s household income 6. Provide applicant with written notice of eligibility 7. Explain PE benefits and coverage span for those eligible 8. Assist applicant with completing and submitting the full MO HealthNet application 9. Send appropriate forms to local office within five days 100 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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11/03/2014 26 Review/Conclusion In this training, the following was covered: Overview of the Presumptive Eligibility Program How Qualified Entities can participate in PE Who is Eligible to Enroll in MO HealthNet through PE? What are the Benefits Determining Eligibility Terms and Definitions Eligibility Requirements Household Composition Income Determination Submitting applications for PE individual(s) 101 (v5) June 4, 2014 Questions/Comments What questions/comments do you have? 102 (v5) June 4, 2014 Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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Application for Presumptive Eligibility
Use this form to find out if you qualify for presumptive eligibility for MO HealthNet at a qualified hospital or clinic. Presumptive Eligibility offers you and your family immediate access to health care while you apply and wait to learn if you qualify for regular MO HealthNet coverage.
To find out if you qualify for regular MO HealthNet, you must complete the Single Streamlined application (IM-1SSL): Online at mydss.mo.gov; By telephone at 1-855-373-9994; or Mail, fax, or drop off a completed IM-1SSL at any Family Support Division Office.
If you need help: Ask your healthcare provider to assist you; Call our Contact Center at 1-855-373-9994. TDD Voice Access: 1-800-735-2466 En Español: Llame a nuestro centro de ayuda gratis al 1-855-373-9994.
Who can qualify for presumptive eligibility for MO HealthNet?
You can qualify for presumptive eligibility for MO HealthNet if you meet all of these rules:
Your income is below the monthly limit;
You do not already have MO HealthNet, except for Uninsured Women's Health Services or Extended Women's Health Services;
You have not had presumptive eligibility for MO HealthNet in the past 12 months. Or, if you are pregnant, you have not had Temporary (TEMP) MO HealthNet during this pregnancy.
You are in one of the groups that qualifies for presumptive eligibility for MO HealthNet:
o Children under age 19; o Parents and caretaker relatives of children under age 19; o Pregnant women; o People under age 26 who were in foster care at age 18; o Women in treatment for breast and cervical cancer.
Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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1 Provider Name: _____________________ Provider Number:________________ Phone number:____________ Tell us about yourself We ask for this information so we can contact you about this application.
Name (first, middle, last)
Home address (leave blank if you don’t have one)
City State ZIP code County
Mailing address (if different from home address)
Phone number (if you have one) Email address (if you have one)
2 Tell us about your family List yourself and the members of your immediate family who live with you. Include your spouse and your children under 19 if they live with you. Do not list other relatives or friends even if they live with you. Name (first, middle, last) Date of birth (XX/XX/ XXXX) Relationship to you Applying for presumptive eligibility for MO HealthNet? (Yes or No) Already has MO HealthNet? (Yes or No) Resident of Missouri? (Yes or No)
Race (optional) Social Security Number (optional) Answer for family members who are applying. If a person is not applying, you do not have to answer these questions for that person. (Same as above)
(Self)
Questions? Ask your hospital representative or call us at 1-855-373-9994. The call is free. TDD Voice: 1-800-735-2466. You can call Monday through Friday 8 a.m.- 5 p.m.
MO XXX-XXXX (06/14)
Page 2 of 4 PE-1SSL Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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4
Other questions 3 Answer these questions for yourself and your family members listed in Section 2. Your answers will make it easier to find out if you and any family members qualify.
Is anyone pregnant? Yes No If yes, who?
How many babies does she expect? ________ What is the pregnancy start date? ________ What is the estimated due date? ________
Is everyone who is applying for MO HealthNet Presumptive Eligibility a U.S. citizen? (If applicant is pregnant, no response is required for this question.) Yes No
If no, list the following information for applicants who are not U.S. Citizens: Name, Immigration status, and date of entry:
Is anyone who is applying for MO HealthNet Presumptive Eligibility a parent, or caretaker relative? Yes No For example, a grandparent who is the main person taking care of a child.
If yes, who?
Was anyone who is applying for MO HealthNet Presumptive Eligibility in foster care 30 days prior to their 18 birthday? Yes No
If yes, who?
Is anyone who is applying for MO HealthNet presumptive eligibility being treated for Yes No breast or cervical cancer?]
If yes, who?
Tell us about your family’s income Write the total income before taxes are taken out for all family members listed in Section 2.
Job income For example, wages, salaries, and self-employment income.
Amount $
How often? (check one) Weekly Biweekly Monthly Yearly
Other income For example, unemployment checks, alimony, or disability payments from the Social Security Administration (“SSDI”). Do not include Supplemental Security Income (“SSI payments”) or any child support you receive.
Amount $
How often? (check one) Weekly Biweekly Monthly Yearly
5 Sign this form here By signing, you are swearing that everything you wrote on this form is true as far as you know. We will keep your information secure and private. Your signature: Date: Questions? Ask your hospital representative or call us at 1-855-373-9994. The call is free. TDD Voice: 1-800-735-2466. You can call Monday through Friday 8 a.m. – 5 p.m.
MO XXX-XXXX (06/14) Page 3 of 4 PE-1SSL Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
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6 7 If you qualify for presumptive eligibility for MO HealthNet, what happens next?
You will get a letter from the hospital or clinic saying you were approved.
You can start using your MO HealthNet Presumptive Eligibility coverage right away for services such as doctor visits, hospital care, and prescription drugs. You can go to any health care provider who accepts MO HealthNet, starting the day you are approved.
o Use the letter provided by the hospital or clinic until your MO HealthNet card arrives. The card should arrive within five business (5) days. If you lose the letter, call us at 1-855-373- 9994 for a replacement.
o If the letter says you qualify for presumptive eligibility for MO HealthNet because you are pregnant, you can get care at outpatient clinics or other places in the community. MO HealthNet Presumptive Eligibility will not cover the cost if you are admitted to a hospital.
If you do not fill out and send the MO HealthNet Single Streamlined application (IM-1SSL) to see if you qualify for regular MO HealthNet, your presumptive eligibility for MO HealthNet coverage will end on the last day of the month after the month you are approved. For example, if you qualified for presumptive eligibility for MO HealthNet in January, it will end on the last day of February.
To see if you qualify for regular MO HealthNet, visit us online at mydss.mo.gov and submit an application, call 1-855-373-9994 to apply, or mail, fax, or drop off a completed IM-1SSL at any Family Support Division Office. The hospital representative can also give you an application.
If you do not qualify for presumptive eligibility for MO HealthNet, what happens next?
You will get a notice from the hospital or clinic saying you were not approved. You cannot appeal the hospital or clinic’s decision. BUT, you can still apply for regular MO HealthNet coverage using the MO HealthNet Single Streamlined application (IM-1SSL): o Online at mydss.mo.gov; o By telephone at 1-855-373-9994; or o Mail, fax, or drop off a completed IM-1SSL at any Family Support Division Office.
Questions? Ask your hospital representative or call us at 1-855-373-9994. The call is free. TDD Voice: 1-800-735-2466. You can call Monday through Friday 8 a.m. – 5 p.m.
MO XXX-XXXX (06/14) Page 4 of 4 PE-1SSL
Transmittal Number: MO 14-0012-MM7 Approval Date: November 3, 2014 Effective Date: January 1, 2014
(spa)(mo-14-0013-mm5)(approval-document)Missouri Medicaid SPA MO-14-0013-MM5: Approval Document (approved June 27, 2014, effective January 1, 2014)#
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Table of Contents
State/Territory Name: MO State Plan Amendment (SPA) #: 14-0013-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106
Division of Medicaid and Children's Health Operations
June 30, 2014
Brian Kinkade, Director Department of Social Services Broadway State Office Building PO Box 1527 Jefferson City, MO 65102
Dear Mr. Kinkade:
On March 31, 2014, the Centers for Medicare & Medicaid Services (CMS) received Missouri’s State Plan Amendment (SPA) transmittal #14-0013-MM5, which describes the Modified Adjusted Gross Income (MAGI) residency requirements. The MAGI based residency requirements are set forth in at 1902(b)(2) of the Act and in 42 CFR § 435.403.
SPA 14-0013-MM5 was approved on June 27, 2014, with an effective date of January 1, 2014, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Missouri State Plan.
If you have any questions regarding this amendment, please contact Karen Hatcher or Debbie Read at (816) 426-5925.
Sincerely,
//s//
Megan Buck
Acting Associate Regional Administrator
for Medicaid and Children’s Health Operations
Enclosure
cc: Dr. Joe Parks Debbie Meller
Kimberly O’Hare
Emily Rowe
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State/Territory name: Missouri Submitted By: Kimberly O'Hara Last Revision Date: Jun 25, 2014 Submit Date: Mar 31, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-0013 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.403 Federal Budget Impact Federal Fiscal Year Amount First Year 2013 $ 0.00 Second Year 2014 $ 0.00 Subject of Amendment Non-Financial Eligibility - State Residency Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 06/30/2014 Transmittal Number: MO 14-0013-MM5 Approval Date: June 27, 2014 Effective Date: January 1, 2014
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SUPERSEDING PAGES OF STATE PLAN MATERIAL
TRANSMITTAL NUMBER:
MO-14-0013 MM5 STATE:
Missouri
PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:
S88 Non-Financial Eligibility- State Residency
PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):
Section 2.3, Page 13, TN 87-9 Attachment 2.6-A: Page 3, Item 4, TN 14-0014 MM6
Transmittal Number: MO 14-0013-MM5 Approval Date: June 27, 2014 Effective Date: January 1, 2014
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Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ Transmittal Number: MO 14-0013-MM5 Approval Date: June 27, 2014 Effective Date: January 1, 2014
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Page 2 of 4 Medicaid Eligibility Otherwise meet the requirements of 42 CFR 435.403. ■ Transmittal Number: MO 14-0013-MM5 Approval Date: June 27, 2014 Effective Date: January 1, 2014
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Page 3 of 4 Medicaid Eligibility Meet the criteria specified in an interstate agreement. Yes No The state has interstate agreements with the following selected states: ■ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): ■ Are IV-E eligible Are in the state only for the purpose of attending school Are out of the state only for the purpose of attending school Retain addresses in both states Other type of individual The state has a policy related to individuals in the state only to attend school. Yes No Otherwise meet the criteria of resident, but who may be temporarily absent from the state. ■ The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Yes No Transmittal Number: MO 14-0013-MM5 Approval Date: June 27, 2014 Effective Date: January 1, 2014
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Page 4 of 4 Medicaid Eligibility Provide a description of the definition: If the individual indicates they still intend to remain a resident, their coverage is not terminated in accordance with 42 CFR 435.403(j)(3). 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 40 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. Transmittal Number: MO 14-0013-MM5 Approval Date: June 27, 2014 Effective Date: January 1, 2014
(spa)(mo-14-0014-mm6)(approval-document)Missouri Medicaid SPA MO-14-0014-MM6: Approval Document (approved June 25, 2014, effective January 1, 2014)#
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Table of Contents
State/Territory Name: MO State Plan Amendment (SPA) #: 14-0014-MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106
Division of Medicaid and Children's Health Operations
June 25, 2014
Brian Kinkade, Director Department of Social Services Broadway State Office Building PO Box 1527 Jefferson City, MO 65102
Dear Mr. Kinkade:
On March 31, 2014, the Centers for Medicare & Medicaid Services (CMS) received Missouri’s state plan amendment (SPA) transmittal #14-0014-MM6, which describes the Modified Adjusted Gross Income (MAGI) citizenship and immigration status requirements. The MAGI based citizenship and immigration status requirements are set forth in at 1902(a)(46)(B) and 1903(v)(2), (3), and (4) of the Act and in 42 CFR § 435.4, 435.406, and 435.956.
SPA 14-0016-MM6 was approved today with an effective date of January 1, 2014, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Missouri State Plan.
If you have any questions regarding this amendment, please contact Karen Hatcher or Debbie Read at (816) 426-5925.
Sincerely,
James G. Scott
Associate Regional Administrator
for Medicaid and Children’s Health Operations
Enclosure
cc: Dr. Joe Parks
Kimberly O’Hara
Emily Rowe //s//
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State/Territory name: Missouri Submitted By: Kimberly O'Hara Last Revision Date: Jun 8, 2014 Submit Date: Mar 31, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) 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-14-0014 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(a)(46)(B); 42 CFR 435.4; 42 CFR 435.406; 42 CFR 435.956; 1903(v)(2), (3), and (4); 8 U.S.C. 1611, 1612,1613, and 1641 Federal Budget Impact Federal Fiscal Year Amount First Year 2013 $ 0.00 Second Year 2014 $ 0.00 Subject of Amendment Non-Financial Eligibility – Citizenship and Non-Citizen Eligibility Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 06/25/2014 Transmittal Number: MO 14-0014-MM6 Approval Date: June 25, 2014 Effective Date: January 1, 2014
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SUPERSEDING PAGES OF STATE PLAN MATERIAL
TRANSMITTAL NUMBER:
14-0014 MM6 STATE:
Missouri
PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:
S89 Non-Financial Eligibility- Citizenship and Non-Citizen Eligibility PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):
Attachment 2.6-A, Page 2, Item 3, Subparagraphs (a) and (b), TN 92-06 Attachment 2.6-A, Page 3, Item 3, Subparagraphs (c), TN 91-44
Transmittal Number: MO 14-0014-MM6 Approval Date: June 25, 2014 Effective Date: January 1, 2014
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Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility S89 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ✔ The state provides Medicaid eligibility to otherwise eligible individuals: ■ Who are citizens or nationals of the United States; and
■ 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); and ■ 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), 1902(ee) of the SSA and 42 CFR 435.406, and 956.
■ 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 verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The date benefits are furnished is: The date of application containing the declaration of citizenship or immigration status. The date the reasonable opportunity notice is sent. Other date, as described: Transmittal Number: MO 14-0014-MM6 Approval Date: June 25, 2014 Effective Date: January 1, 2014
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Page 2 of 3 Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. Yes No An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); Transmittal Number: MO 14-0014-MM6 Approval Date: June 25, 2014 Effective Date: January 1, 2014
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Page 3 of 3 Medicaid Eligibility 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ✔ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ■ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). ■ 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 40 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. Transmittal Number: MO 14-0014-MM6 Approval Date: June 25, 2014 Effective Date: January 1, 2014
(spa)(mo-19-0003)(approval-document)Missouri Medicaid SPA MO-19-0003: Approval Document (approved August 15, 2019, effective September 1, 2019)#
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Table of Contents
State/Territory Name: MO State Plan Amendment (SPA) #: 19-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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Records / Submission Packages MO - Submission Package - MO2018MS0009O - (MO-19-0003) - Health Homes CMS-10434 OMB 0938-1188 Package Information Package ID MO2018MS0009O Program Name Missouri-2 Health Home Services SPA ID MO-19-0003 Version Number 4 Submitted By Marissa Crump Package Disposition Priority Code P2 Submission Type OŰcial State MO Region Kansas City, KS Package Status Approved Submission Date 6/6/2019 Approval Date 8/15/2019 1:20 PM EDT Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Kansas City Regional OŰce 601 E. 12th Street, Suite 355 Kansas City, MO 64106 Division of Medicaid and Children's Health Operations August 15, 2019 Todd Richardson Director MO HealthNet Division 615 Howerton Court Jeſerson City, MO 65109 Re: Approval of State Plan Amendment MO-19-0003 Missouri-2 Health Home Services Dear Mr. Richardson: On June 06, 2019, the Centers for Medicare and Medicaid Services (CMS) received Missouri State Plan Amendment (SPA) MO-19-0003 for Missouri-2 Health Home Services to is to add new qualifying conditions and risk factors for enrollment.. We approve Missouri State Plan Amendment (SPA) MO-19-0003 on August 15, 2019 with an eſective date(s) of September 01, 2019. For payments made to Health Homes providers for Health Homes participants who newly qualify based on the Health Homes program’s increase in conditions covered under this amendment, a medical assistance percentage (FMAP) rate of 90% applies to such payments for the period 9/1/2019 to 6/30/2021. The FMAP rate for payments made to health homes providers will return to the state's published FMAP rate at the end of the enhanced match period. The Form CMS-64 has a designated category of service Line 43 for states to report health homes services expenditures for enrollees with chronic conditions. Name Date Created No items available If you have any questions regarding this amendment, please contact Karen Hatcher at 8169165378 or karen.hatcher@cms.hhs.gov. Sincerely, James G. Scott Director Division of Medicaid Field Operations - North Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID N/A SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date N/A State Information State/Territory Name: Missouri Medicaid Agency Name: MO HealthNet Division Submission Component State Plan Amendment Medicaid CHIP
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Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID N/A SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date N/A SPA ID and Eſective Date SPA ID MO-19-0003 Reviewable Unit Proposed Eſective Date Superseded SPA ID Health Homes Intro 9/1/2019 16-0002 Health Homes Geographic Limitations 9/1/2019 16-0002 Health Homes Population and Enrollment Criteria 9/1/2019 16-0002 Health Homes Providers 9/1/2019 16-0002 Health Homes Service Delivery Systems 9/1/2019 16-0002 Health Homes Payment Methodologies 9/1/2019 16-0002 Health Homes Services 9/1/2019 16-0002 Health Homes Monitoring, Quality Measurement and Evaluation 9/1/2019 16-0002
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Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID N/A SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives Missouri is amending its approved Primary Care Health Home (PCHH) State Plan Amendment 16-002 dated July 5, 2016 to add new qualifying conditions and risk factors for enrollment. The PCHH was originally implemented 1/1/2012 and its integrated team care concept has shown and continues to show success in meeting the following goals: - Reduction in avoidable hospitalizations - Reduction in emergency department visits - Improvement in clinical measures such as hypertension, hemoglobin A1C, and cholesterol levels -Positive impact to quality of life for participants and providers -Reduction in healthcare costs associated with avoidable use of healthcare services Missouri's PCHH works with primary care providers throughout the state in the provision of team-based care to qualifying individuals enrolled in their health homes. Care teams include a health home director, nurse care manager, behavioral health consultant and care coordinator who are paid through the PCHH per-member-per-month payment, and other clinic staſ who work in collaboration with the PCHH team such as physicians, nurse practitioners, clinic managers, pharmacists, nutritionists, information technology, etc. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2020 $-57475 Second 2021 $-62700 Federal Statute / Regulation Citation Section 2703 of the Aſordable Care Act and Section 1945 of the Social Security Act
Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available
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Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID N/A SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date N/A Governor's OŰce Review No comment Comments received No response within 45 days Other
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Submission - Public Comment MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID N/A SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date N/A Indicate whether public comment was solicited with respect to this submission. Indicate how public comment was solicited: Select the type of website Date of Posting: Jul 26, 2018 Website URL: https://dss.mo.gov/mhd/alerts~public- notices.htm Upload copies of public notices and other documents used Name Date Created public-notice-7-26-18 8/8/2018 5:10 PM EDT PublicNotice-ProspectiveAmendment 8/13/2019 3:29 PM EDT Upload with this application a written summary of public comments received (optional) Name Date Created No items available Indicate the key issues raised during the public comment period (optional) Summarize comments: We received a suggestion that in addition to children currently in foster care, we add children who have ever been in foster care as an eligible at risk criteria for enrollment in the Primary Care Health Home initiative. Summarize response: The internal review/approval process of this SPA amendment brought awareness about other MO HealthNet/state programs addressing care management of children in foster care. A decision was made to delay seeking CMS approval to add foster care as a qualifying condition/risk factor for the Primary Care Health Home pending a thorough review of these programs. All references to adding foster care have been deleted from this SPA. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Website of the State Medicaid Agency or Responsible Agency Website for State Regulations Other Public Hearing or Meeting Other method Access Quality Cost Payment methodology Eligibility
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Beneţts Service delivery Other issue
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Submission - Tribal Input MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID N/A SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date N/A Name of Health Homes Program: Missouri-2 Health Home Services One or more Indian health programs or Urban Indian Organizations furnish health care services in this state Yes No
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Submission - Other Comment MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID N/A SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date N/A SAMHSA Consultation Name of Health Homes Program Missouri-2 Health Home Services Date of consultation 6/30/2016 The State provides assurance that it has consulted and coordinated with the Substance Abuse and Mental Health Services Administration (SAMHSA) in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions.
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Health Homes Intro MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Program Authority 1945 of the Social Security Act The state elects to implement the Health Homes state plan option under Section 1945 of the Social Security Act. Name of Health Homes Program Missouri-2 Health Home Services Executive Summary Provide an executive summary of this Health Homes program including the goals and objectives of the program, the population, providers, services and service delivery model used Missouri is amending its approved Primary Care Health Home (PCHH) State Plan Amendment 16-002 dated July 5, 2016 to add a new qualifying condition and risk factor for enrollment. The PCHH was originally implemented 1/1/2012 and its integrated team care concept has shown and continues to show success in meeting the following goals: - Reduction in avoidable hospitalizations - Reduction in emergency department visits - Improvement in clinical measures such as hypertension, hemoglobin A1C, and cholesterol levels -Positive impact to quality of life for participants and providers -Reduction in healthcare costs associated with avoidable use of healthcare services Missouri's PCHH works with primary care providers throughout the state in the provision of team-based care to qualifying individuals enrolled in their health homes. Care teams include a health home director, nurse care manager, behavioral health consultant and care coordinator who are paid through the PCHH per- member-per-month payment, and other clinic staſ who work in collaboration with the PCHH team such as physicians, nurse practitioners, clinic managers, pharmacists, nutritionists, information technology, etc. General Assurances The state provides assurance that eligible individuals will be given a free choice of Health Homes providers. The states provides assurance that it will not prevent individuals who are dually eligible for Medicare and Medicaid from receiving Health Homes services. The state provides assurance that hospitals participating under the state plan or a waiver of such plan will be instructed to establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated Health Homes providers. The state provides assurance that FMAP for Health Homes services shall be 90% for the ţrst eight ţscal quarters from the eſective date of the SPA. After the ţrst eight quarters, expenditures will be claimed at the regular matching rate. The state provides assurance that it will have the systems in place so that only one 8-quarter period of enhanced FMAP for each health homes enrollee will be claimed. The state provides assurance that there will be no duplication of services and payment for similar services provided under other Medicaid authorities.
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Health Homes Geographic Limitations MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Health Homes services will be available statewide Health Homes services will be limited to the following geographic areas Health Homes services will be provided in a geographic phased-in approach
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Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Categories of Individuals and Populations Provided Health Homes Services The state will make Health Homes services available to the following categories of Medicaid participants Categorically Needy (Mandatory and Options for Coverage) Eligibility Groups Medically Needy Eligibility Groups
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Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Population Criteria The state elects to oſer Health Homes services to individuals with: Specify the conditions included: Name Description Mental Health Condition Anxiety and/or Depression Developmental Disabilities Developmental disabilities present additional challenges to people trying to manage chronic physical and behavioral health conditions Substance Use Disorder Restricted to primary care organizations that have at least one clinician certiţed to provide medication-assisted treatment Chronic Pain Chronic Pain is pain that lasts past the time of normal tissue healing. Risk stratiţcation for severity of pain as well as for worsening condition and/or opioid dependency will be incorporated into eligibility. Qualiţed participant eligibility shall be limited to chronic non-cancer neck and back pain, chronic pain post trauma [for example, motor vehicle collision], and others as determined medically necessary through a prior approval process. Specify the conditions included: Name Description Two or more chronic conditions Mental Health Condition Substance Use Disorder Asthma Diabetes Heart Disease BMI over 25 Other (specify): One chronic condition and the risk of developing another Mental Health Condition Substance Use Disorder Asthma Diabetes Heart Disease BMI over 25 Other (specify):
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Name Description Tobacco Use Tobacco use is considered an at- risk behavior for chronic conditions such as asthma and CVD Developmental Disabilities Developmental disabilities can present challenges to people trying to manage chronic physical and behavioral conditions Diabetes Diabetes is considered an at-risk condition for chronic conditions such as CVD and BMI over 25 Mental Health Condition Anxiety and/or Depression Obesity Obesity is considered an at-risk condition for chronic conditions such as CVD and DM Pediatric Asthma Pediatric asthma is considered an at-risk condition for higher rates of school absenteeism; inadequate sleep leading to short attention, impulsivity, emotional liability, hyperactivity, irritability, cognitive and speech-language problems, and poor academic outcomes; and anxiety, depression, and other emotional and behavioral problems Chronic Pain Chronic pain can lead to other problems in individuals such as substance use disorder, overweight/obesity, depression, anxiety or low self-esteem. Other physical or somatic problems such as gastrointestinal ulcers can also originate due to these secondary emotional problems. Specify the criteria for at risk of developing another chronic condition: See above One serious and persistent mental health condition
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Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Enrollment of Participants Participation in a Health Homes is voluntary. Indicate the method the state will use to enroll eligible Medicaid individuals into a Health Home: Describe the process used: MO HealthNet will work with provider organizations to identify existing users of that healthcare system who are eligible for primary care health home services. These individuals will initially be auto-assigned to PCHH providers based on qualifying conditions. Individuals enrolled will be informed via US mail or phone call. The notice will describe PCHH services, as well as the process to opt out of receiving PCHH services or change PCHH providers, and that these decisions will not impact their existing services. Once an individual is enrolled, the PCHH will notify other healthcare providers (e.g. specialists) about the goals and types of PCHH services the participant will be receiving, as well as encourage their participation in care coordination. Other individuals with qualifying chronic conditions who don’t use a PCHH provider as their primary care provider may request to enroll. Potentially eligible individuals may be informed about and referred to a PCHH provider by a hospital or ED. Eligibility for PCHH services will be identiţable through the state’s comprehensive Medicaid EHR. After the initial enrollment period, PCHH organizations can continue to identify and enroll eligible individuals through an enrollment process. Name Date Created PCHH Auto Enrollment Letter 7/6/2018 1:32 PM EDT Opt-In to Health Homes provider Referral and assignment to Health Homes provider with opt-out Other (describe) The state provides assurance that it will clearly communicate the individual's right to opt out of the Health Homes beneţt or to change Health Homes providers at any time and agrees to submit to CMS a copy of any letter or communication used to inform the individuals of the Health Homes beneţt and their rights to choose or change Health Homes providers or to elect not to receive the beneţt.
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Health Homes Providers MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Types of Health Homes Providers Indicate the Health Homes Designated Providers the state includes in its program and the provider qualiţcations and standards Describe the Provider Qualiţcations and Standards see "Other Provider Standards" below Describe the Provider Qualiţcations and Standards see "Other Provider Standards" below Describe the Provider Qualiţcations and Standards see "Other Provider Standards" below Provider Type Description Primary care clinics operated by hospitals see "Other Provider Standards" below Provider Infrastructure Describe the infrastructure of provider arrangements for Health Home Services Designated providers of primary care health home services will be federally qualiţed health centers (FQHCs), rural health clinics (RHCs), clinical practices/clinical group practices, and primary care clinics operated by hospitals. All designated providers will be required to meet state qualiţcations. Practice sites will be physician-led and shall form a health team comprised of a primary care physician (i.e., family practice, internal medicine, or pediatrician) or nurse practitioner, a licensed nurse or medical assistant, behavioral health consultant, a nurse care manager and the practice administrator or oŰce manager. The team is supported as needed by the care coordinator and health home director. In addition, other optional team members may include a nutritionist, diabetes educator, public school personnel and others as appropriate and available. Optional team members are identiţed for inclusion at the request of the patient, responsible caregiver or by the care manager. The designated provider is responsible for locating and conducting outreach to optional team members. Optional team members will not be included in the review to determine selection of primary care health homes. All members of the team will be responsible for ensuring that care is person-centered, culturally competent and linguistically capable. The Health Home Director, Nurse Care Manager, Behavioral Health Consultant, and Care Coordinator’s time will be covered under the PMPM rate described in the Payment Methodology section below. Supports for Health Homes Providers Describe the methods by which the state will support providers of Health Homes services in addressing the following components 1. Provide quality-driven, cost-eſective, culturally appropriate, and person- and family- centered Health Homes services Designated Providers Physicians Clinical Practices or Clinical Group Practices Rural Health Clinics Community Health Centers Community Mental Health Centers Home Health Agencies Case Management Agencies Community/Behavioral Health Agencies Federally Qualiţed Health Centers (FQHC) Other (Specify) Teams of Health Care Professionals Health Teams
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2. Coordinate and provide access to high quality health care services informed by evidence-based clinical practice guidelines 3. Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders 4. Coordinate and provide access to mental health and substance abuse services 5. Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care 6. Coordinate and provide access to chronic disease management, including self-management support to individuals and their families 7. Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services 8. Coordinate and provide access to long-term care supports and services 9. Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services 10. Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate 11. Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level Description Designated health homes will be supported in transforming service delivery by participating in statewide learning activities. Given providers' varying levels of experience with practice transformation approaches, the State will assess providers to determine learning needs. Health homes will therefore participate in a variety of learning supports, up to and including learning collaboratives, speciţcally designed to instruct organizations to operate as Health Homes and provide care using a whole person approach that integrates behavioral health, primary care and other needed services and supports. Learning activities will be supplemented with periodic calls to reinforce the learning sessions, practice coaching, and monthly practice reporting and feedback. Other Health Homes Provider Standards The state's requirements and expectations for Health Homes providers are as follows 1. In addition to being a Federally Qualiţed Health Center, Rural Health Clinic, clinical practice/clinical group practice, or primary care clinic operated by a hospital, each primary care health home provider must meet state qualiţcations, which may be amended from time-to-time as necessary and appropriate, but minimally require that each primary care health home: a. Have a substantial percentage of its patients enrolled in Medicaid, with special consideration given to those with a considerable volume of needy individuals, deţned as receiving medical assistance from Medicaid or the Children’s Health Insurance Program (CHIP), furnished uncompensated care by the provider, or furnished services at either no cost or reduced based on a sliding scale. Patient percentage requirements will be determined by the state; b. Have strong, engaged leadership personally committed to and capable of leading the practice through the transformation process and sustaining transformed practice processes as demonstrated by through the application process and agreement to participate in learning activities, including in-person sessions and regularly scheduled phone calls; c. Meet state requirements for patient empanelment (i.e., each patient receiving primary care health home services must be assigned to a physician); d. Meet the state’s minimum access requirements. Prior to implementation of primary care health home service coverage, provide assurance of enhanced patient access to the health team, including the development of alternatives to face-to-face visits, such as telephone or email, 24 hours per day 7 days per week; e. Have a formal and regular process for patient input into services provided, quality assurance, access and other practice aspects; f. Have completed EMR implementation and been using the EMR as its primary medical record solution, to eprescribe, and to generate, or support the generation of through a third party such as a data repository, clinical quality measures relevant to improving chronic illness care and prevention for at least six months prior to the beginning of primary care health home services; g. Actively utilize MO HealthNet’s comprehensive electronic health record for care coordination and prescription monitoring for Medicaid participants; h. Utilize an interoperable patient registry to input annual metabolic screening results, track and measure care of individuals, automate care reminders, and produce exception reports for care planning; i. Within three months of primary care health home service implementation, have developed a relationship with regional hospital(s) or system(s) to ensure a process for transitional care planning, to include communication of inpatient admissions of primary care health home participants, as well as maintain a mutual awareness and collaboration to identify individuals seeking ED services that might beneţt from connection with a primary care health home site, and in addition motivate hospital staſ to notify the primary care health home’s designated staſ of such opportunities; the state will assist in facilitating this relationships as needed; j. Agree to convene regular, ongoing and documented internal primary care health home team meetings to plan and implement goals and objectives of practice transformation; k. Agree to participate in CMS and state-required evaluation activities; l. Agree to develop required reports describing primary care health home activities, eſorts and progress in implementing primary care health home services (e.g., monthly clinical quality indicators reports utilizing clinical data in disease registries, breakdown of primary care health home service staſ time and activities); m. Maintain compliance with all of the terms and conditions as a primary care health home provider or face termination as a provider of primary care health home services; and n. Present a proposed health home delivery model that the state determines to have a reasonable likelihood of being cost-eſective. Cost eſectiveness will be determined based on the size of the primary care health home, Medicaid caseload, percentage of caseload with eligible chronic conditions of patients and other factors to be determined by the state.
2. Ongoing Provider Certiţcation Requirements a. Each practice must: 1. Develop quality improvement plans to address gaps and opportunities for improvement identiţed during and after the application process; 2. Demonstrate development of fundamental medical home functionality at 6 months and 12 months through an assessment process to be applied by the state; 3. Demonstrate signiţcant improvement on clinical outcome and process indicators speciţed by and reported to the state, and 4. Achieve NCQA Patient-Centered Medical Home recognition under most current standards by month 18 from the date at which supplemental payments commence; or 5. Meet equivalent/equitable recognition standards approved by the state as such standards are developed.
3. For health home organizations that want to enroll individuals with substance use disorder, at least one physician at each applicable practice site must qualify* and apply for a waiver** under the Drug Addiction Treatment Act of 2000 (DATA 2000). *Under the Drug Addiction Treatment Act of 2000 (DATA 2000), qualiţed physicians may apply for waivers to treat opioid dependency with approved buprenorphine products in any settings in which they are qualiţed to practice, including an oŰce, community hospital, health department, or correctional facility. A “qualifying physician” is speciţcally deţned in DATA 2000 as one who is: • Licensed under state law (excluding physician assistants or nurse practitioners) • Registered with the Drug Enforcement Administration (DEA) to dispense controlled substances
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• Required to treat no more than 30 patients at a time within the ţrst year • Qualiţed by training and/or certiţcation Also, in order to maintain a waiver, a physician must be capable of referring patients to counseling and other services. **To qualify for a waiver, a licensed physician (M.D. or D.O.) must meet any one or more of the following criteria and provide supporting documentation for all that apply: • Hold a subspecialty board certiţcation in addiction psychiatry from the American Board of Medical Specialties • Hold an addiction certiţcation from the American Society of Addiction Medicine (ASAM) • Hold a subspecialty board certiţcation in addiction medicine from the American Osteopathic Association • Have completed required training for the treatment and management of patients with opioid use disorders. This involves not less than eight hours of training through classroom situations, seminars at professional society meetings, electronic communications, or training otherwise provided by ASAM and other organizations. • Have participated as an investigator in one or more clinical trials leading to the approval of a narcotic medication in Schedule III, IV, or V for maintenance or detoxiţcation treatment. The physician’s participation should be conţrmed in a statement by the sponsor of the approved medication to Department of Health and Human Services (HHS). • Have other training or experience that the state medical licensing board (of the state in which the physician will provide maintenance or detoxiţcation treatment) considers a demonstration of the physician’s ability to treat and manage patients with opioid dependency. • Have completed other training or experience that HHS considers a demonstration of the physician’s ability to treat and manage patients with an opioid dependency. The criteria of HHS for this training or experience will be established by regulation.
4. Organizations that want to enroll people with chronic pain diagnoses must, at a minimum, regularly participate in interactive video conferences on chronic pain that include pain management specialists who will provide guidance on the management of people with a chronic pain diagnosis. When possible, organizations are encouraged to directly collaborate with a pain management specialist on the management of these individuals. A pain management specialist is deţned as a licensed physician (MD or DO) who is board certiţed in anesthesiology or pain management. Name Date Created No items available Health Homes Service Delivery Systems MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Identify the service delivery system(s) that will be used for individuals receiving Health Homes services Fee for Service PCCM Risk Based Managed Care Other Service Delivery System
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Payment Methodology The State's Health Homes payment methodology will contain the following features Describe below See description in Rate Development section below. Describe any variations in payment based on provider qualiţcations, individual care needs, or the intensity of the services provided Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Health Home services. The agency’s per-member-per-month rate was set as of January 1, 2016 and is eſective for services provided on or after that date. Fee for Service Individual Rates Per Service Per Member, Per Month Rates Fee for Service Rates based on Severity of each individual's chronic conditions Capabilities of the team of health care professionals, designated provider, or health team Other Comprehensive Methodology Included in the Plan Incentive Payment Reimbursement PCCM (description included in Service Delivery section) Risk Based Managed Care (description included in Service Delivery section) Alternative models of payment, other than Fee for Service or PMPM payments (describe below)
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Agency Rates Describe the rates used Eſective Date 1/1/2016 Website where rates are displayed http://dss.mo.gov/mhd/cs/health-homes/pdf/pchh-per-member-per-month- rates.pdf. FFS Rates included in plan Comprehensive methodology included in plan The agency rates are set as of the following date and are eſective for services provided on or after that date
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Rate Development Provide a comprehensive description in the SPA of the manner in which rates were set 1. In the SPA please provide the cost data and assumptions that were used to develop each of the rates 2. Please identify the reimbursable unit(s) of service 3. Please describe the minimum level of activities that the state agency requires for providers to receive payment per the deţned unit 4. Please describe the state's standards and process required for service documentation, and 5. Please describe in the SPA the procedures for reviewing and rebasing the rates, including the frequency with which the state will review the rates, and the factors that will be reviewed by the state in order to understand if the rates are economic and eŰcient and suŰcient to ensure quality services. Comprehensive Description Cost Assumptions/Factors Used to Determine Payment: Missouri will pay PCHH the cost of staſ primarily responsible for delivery of services not covered by other reimbursement (Nurse Care Managers, Behavioral Health Consultants, Care Coordinators and Health Home Directors) whose duties are not otherwise reimbursable by MO HealthNet. In addition, PCHH Health Homes receive payments related to Health Home speciţc training, technical assistance, administration, and data analytics.
All payments are contingent on the Health Home meeting the requirements set forth in their Health Home applications, as determined by the State of Missouri. Failure to meet such requirements is grounds for revocation of Health Home status and termination of payments. Clinical Care Management per-member-per-month (PMPM) payment:
• Staſ cost is based on a provider survey of all PCHH statewide and includes fringe, operating & indirect costs.
• All PCHH providers will receive the same PMPM rate.
• The PMPM method will be reviewed periodically to determine if the rate is economically eŰcient and consistent with quality of care.
Minimum Criteria for Payment The criteria required for receiving the PMPM rate payment is: A. The person is identiţed as meeting PCHH eligibility criteria on the State-run health home patient registry; B. The person is enrolled as a health home member at the billing health home provider; C. The minimum health home service required to merit payment of the PMPM is that the person has received Care Management monitoring for treatment gaps; or another health home service was provided that was documented by a health home director and/or nurse care manager; and D. The health home will report that the minimal service required for the PMPM payment occurred on a monthly health home activity report.
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Assurances Describe below how non- duplication of payment will be achieved Managed Care: All Health Home payments including those for MO HealthNet (MHN) participants enrolled in managed care plans will be made directly from MHN to the Health Home provider. As a result of the additional value that managed care plans will receive from MHN direct paid Health Home services, the managed care plan is not required to provide care coordination or case management services that would duplicate the CMS reimbursed health home services (i.e. the conditions for which an individual was enrolled in the Health Home). This Health Home delivery design and payment methodology will not result in any duplication of payment between Health Homes and managed care. The managed care plan will be informed of its members that are in Health Home services and a managed care plan contact person will be provided for each Health Home provider to allow for coordination of care.
• The managed care plan will be required to inform either the individual’s Health Home or MO Health Net of any inpatient admission or discharge of a Health Home member that the plan learns of through its inpatient admission initial authorization and concurrent review processes within 24 hours.
• The PCHH team will provide Health Home services in collaboration with MCO network primary care physicians in the same manner as they will collaborate with any other primary care physician who is serving as the PCP of an individual enrolled in the PCHH. Optional Supporting Material Upload Name Date Created No items available The State provides assurance that it will ensure non-duplication of payment for services similar to Health Homes services that are oſered/covered under a diſerent statutory authority, such as 1915(c) waivers or targeted case management. The state has developed payment methodologies and rates that are consistent with section 1902(a)(30)(A). The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule, unless otherwise described above. The State provides assurance that it shall reimburse providers directly, except when there are employment or contractual arrangements consistent with section 1902(a)(32).
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Health Homes Services MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Service Deţnitions Provide the state's deţnitions of the following Health Homes services and the speciţc activities performed under each service Comprehensive Care Management Deţnition Comprehensive care management services involve: a. Identiţcation of high-risk individuals and use of client information to determine level of participation in care management services; b. assessment of preliminary service needs; treatment plan development, which will include client goals, preferences and optimal clinical outcomes; c. assignment by the care manager of health team roles and responsibilities; d. development of treatment guidelines that establish clinical pathways for health teams to follow across risk levels or health conditions; e. monitoring of individual and population health status and service use to determine adherence to or variance from treatment guidelines and; f. development and dissemination of reports that indicate progress toward meeting outcomes for client satisfaction, health status, service delivery and costs.
Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum MO HealthNet maintains a web-based electronic health record (EHR) accessible to enrolled Medicaid providers, including CMHCs, primary care practices and schools. The tool is a HIPAA-client portal that enables providers to: a. Download paid claims data submitted for an enrollee by any provider over the past three years (e.g., drug claims, diagnosis codes, CPT codes); b. View dates and providers of hospital emergency department services; c. Identify clinical issues that aſect an enrollee’s care and receive best practice information; d. Prospectively examine how speciţc preferred drug list (PDL) and clinical edit criteria would aſect a prescription for an individual enrollee and determine if a prescription meets requirement for Medicaid payment; e. Electronically request a drug prior authorization or clinical edit override; pre-certiţcations for radiology, durable medical equipment (DME), optical and inpatient services; f. Identify approved or denied drug prior authorizations or clinical edit overrides or medical precertiţcations previously issues and transmit a prescription electronically to the enrollee’s pharmacy of choice; and g. Review laboratory data and clinical trait data; h. Determine medication adherence information and calculate medication possession ratios (MPR); and i. Oſer counseling opportunities for pharmacists through a point of service medication therapy management (MTM) module. Scope of service The service can be provided by the following provider types Provider Type Description Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)
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Provider Type Description Rural health clinics, FQHCs, clinical practices and clinical group practices, primary care practices operated by hospitals These are the types of providers that participate in Missouri's PCHH program Care Coordination Deţnition Care Coordination is the implementation of the individualized treatment plan (with active client involvement) through appropriate linkages, referrals, coordination and follow-up to needed services and supports, including referral and linkages to long term services and supports. Speciţc activities include, but are not limited to: appointment scheduling, conducting referrals and follow-up monitoring, participating in hospital discharge processes and communicating with other providers and clients/family members. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum MO HealthNet maintains a web-based electronic health record (EHR) accessible to enrolled Medicaid providers, including CMHCs, primary care practices, and schools. The tool is a HIPAA-client portal that enables providers to: a. Download paid claims data submitted for an enrollee by any provider over the past three years (e.g., drug claims, diagnosis codes, CPT codes); b. View dates and providers of hospital emergency department services; c. Identify clinical issues that aſect an enrollee’s care and receive best practice information; d. Prospectively examine how speciţc preferred drug list (PDL) and clinical edit criteria would aſect a prescription for an individual enrollee and determine if a prescription meets requirement for Medicaid payment; e. Electronically request a drug prior authorization or clinical edit override; pre-certiţcations for radiology, durable medical equipment (DME), optical and inpatient services; f. Identify approved or denied drug prior authorizations or clinical edit overrides or medical precertiţcations previously issues and transmit a prescription electronically to the enrollee’s pharmacy of choice; and g. Review laboratory data and clinical trait data; h. Determine medication adherence information and calculate medication possession ratios (MPR); and i. Oſer counseling opportunities for pharmacists through a point of service medication therapy management (MTM) module. Scope of service The service can be provided by the following provider types Provider Type Description Rural health clinics, FQHCs, clinical practices and clinical group practices, primary care practices operated by hospitals These are the types of providers that participate in Missouri's PCHH program Health Promotion Deţnition Health promotion services shall minimally consist of providing health education speciţc to an individual’s chronic conditions, development of self-management plans with the individual, education regarding the importance of immunizations and screenings, child physical and emotional development, providing support for improving social networks and providing health promoting lifestyle interventions, including but not limited to, substance use prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and prevention and increasing physical activity. Health promotion services also assist patients to participate in the implementation of the treatment plan and place a strong emphasis on person-centered empowerment to understand and self-manage chronic health conditions. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum A module of the MO HealthNet comprehensive, web-based EHR allows enrollees to look up their own healthcare utilization and receive the same content in laypersons’ terms. The information facilitates self-management and monitoring necessary for an enrollee to attain the highest levels of health and functioning. Utilization data available through the module includes: a. Administrative claims data for the past three years; Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)
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b. Cardiac and diabetic risk calculators; c. Chronic health condition information awareness; d. A drug information library; and e. The functionality to create a personal health plan and discussion lists to use with healthcare providers. Scope of service The service can be provided by the following provider types Provider Type Description Rural health clinics, FQHCs, clinical practices and clinical group practices, and primary care clinics operated by hospitals These are the types of providers that participate in Missouri's PCHH program Comprehensive Transitional Care from Inpatient to Other Settings (including appropriate follow-up) Deţnition In conducting comprehensive transitional care, a member of the health team provides care coordination services designed to streamline plans of care, reduce hospital admissions, ease the transition to long term services and supports and interrupt patterns of frequent hospital emergency department use. The health team member collaborates with physicians, nurses, social workers, discharge planners, pharmacists, and others to continue implementation of the treatment plan with a speciţc focus on increasing clients’ and family members’ ability to manage care and live safely in the community, and shift the use of reactive care and treatment to proactive health promotion and self management. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum MO HealthNet maintains an initial and concurrent authorization of stay tool which requires hospitals to notify MO HealthNet (via accessing the online authorization tool) within 24 hours of a new admission of any Medicaid enrollee and provide information about diagnosis, condition and treatment for authorization of an inpatient stay. MO HealthNet and the Department of Mental Health are working with the vendor to develop capacity for a daily data transfer listing all new hospital admissions discharges. This information will be transferred to the state’s data analytics contractor which will match it to a list of all persons assigned and/or enrolled in a healthcare home. The contractor would then immediately notify the healthcare home provider of the admission, which would enable the primary care health home provider to: a. Use the hospitalization episode to locate and engage persons in need of primary care health home services; b. Perform the required continuity of care coordination between inpatient and outpatient; and c. Coordinate with the hospital to discharge and avoid readmission as soon as possible. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers
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Provider Type Description Rural health clinics, FQHCs, clinical practices and clinical group practices, and primary care clinics operated by hospitals These are the types of providers that participate in Missouri's PCHH program Individual and Family Support (which includes authorized representatives) Deţnition Individual and family support services activities include, but are not limited to: advocating for individuals and families, assisting with obtaining and adhering to medications and other prescribed treatments. In addition, health team members are responsible for identifying resources for individuals to support them in attaining their highest level of health and functioning in their families and in the community, including transportation to medically necessary services. A primary focus will be increasing health literacy, ability to self-manage their care and facilitate participation in the ongoing revision of their care/treatment plan. For individuals with DD the health home team will refer to and coordinate with the approved DD case management entity for services more directly related to Habilitation and coordinate with the approved DD case management entity for services more directly related a particular healthcare condition. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum A module of the MO HealthNet comprehensive, web-based EHR allows enrollees to look up their own healthcare utilization and receive the same content in laypersons’ terms. The information facilitates self-management and monitoring necessary for an enrollee to attain the highest levels of health and functioning. Utilization data available through the module includes: a. Administrative claims data for the past three years; b. Cardiac and diabetic risk calculators; c. A drug information library; and d. The functionality to create a personal health plan and discussion lists to use with healthcare providers. Scope of service The service can be provided by the following provider types Provider Type Description Rural health clinics, FQHCs, clinical practices and clinical group practices, and primary care clinics operated by hospitals These are the types of providers that participate in Missouri's PCHH program Referral to Community and Social Support Services Deţnition Referral to community and social support services involves providing assistance for clients to obtain and maintain eligibility for healthcare including long term services and supports, disability beneţts, housing, personal need and legal services, as examples. For individuals with DD the health home team will refer to and coordinate with the approved DD case management entity for this service. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)
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Primary care health home providers will be encouraged to monitor continuing Medicaid eligibility using the DFS eligibility website and data base. MO HealthNet and the Department of Mental Health will also reţne processes to notify primary care health home providers of impending eligibility lapses (e.g., 60 days in advance). Scope of service The service can be provided by the following provider types Provider Type Description Rural health clinics, FQHCs, clinical practices and clinical group practices, and primary care practices operated by hospitals These are the types of providers that participate in Missouri's PCHH program Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify)
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Health Homes Services MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Health Homes Patient Flow Describe the patient Ťow through the state's Health Homes system. Submit with the state plan amendment Ťow-charts of the typical process a Health Homes individual would encounter PCHH. PCHH providers also query their EHR systems for this purpose. PCHH staſ contact them to explain PCHH, and that they will be assigned a Nurse Care Manager (NCM) to assist them in improving their health/wellness goals, that these services are free, participation is optional, and choosing not to enroll will have NO impact on their currents services. Enrollment forms are submitted for interested individuals. Once enrolled, the NCM meets with participants to review history and health status, and to discuss wellness, health, and self-management goals. A care plan including these topics is developed with input from the participants. The NCM (or behavioral health consultant) attempts to see all PCHH participants when they come for visits or other services. When patients do not have appointments, PCHH staſ contact them by phone or secure email and/or monitor them (CyberAccess review, check on referrals, share targeted educational information, and review reports provided by MO HealthNet that show recent ER visits or hospitalizations, high utilization of ERs or excessive hospitalizations, and opportunities for care coordination with other program (e.g. home & community-based services or developmental disabilities). Staſ members also provide needed coordination, referral, and follow-up for other services such as specialty care, ongoing behavioral health care, and community resources. PCHHs often oſer health/wellness classes (e.g. smoking cessation or nutrition), and encourage PCHH enrollees to participate. NCMs provide transition of care coordination and attempt contact within 72 hours of hospital discharge or ER visit to do a medication reconciliation and ensure appropriate follow-up care. If patients achieve their goals and their chronic conditions are well-controlled, they may be discharged from PCHH to the provider’s general patient-centered medical home. Name Date Created PCHH Flow Chart 12242015 6/26/2018 4:53 PM EDT
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Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Monitoring Describe the state's methodology for calculating cost saving (and report cost savings annually in Quality Measure Report). Include savings that result from improved coordination of care and chronic disease management achieved through the Health Homes Program, including data sources and measurement speciţcations, as well as any savings associated with dual eligibles, and if Medicare data was available to the state to utilize in arriving at its cost-savings estimates The State will annually perform an assessment of cost savings using a pre-/post-period comparison. The assessment will include total Medicaid savings for the intervention group and will be subdivided by category of service. It will also be broken out for each primary care health home. The data source will be Medicaid claims and the measure will be PMPM Medicaid expenditures. Savings calculations will be trended for inŤation, and will truncate the claims of high-cost outliers annually exceeding three standard deviations of the mean. Savings calculations will include the cost of PMPM payments received by primary care health home providers. The assessment will also include the performance measures enumerated in the Quality Measures section. Describe how the state will use health information technology in providing Health Homes services and to improve service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider) To facilitate the exchange of health information in support of care for patients receiving or in need of primary care health home services, the state will utilize several methods of health information technology (HIT). Following is a summary of HIT currently available for primary care health home providers to conduct comprehensive care management, care coordination, health promotion and individual and family support services. Also included is a description of the state’s process to improve health information exchange (HIE) for comprehensive transitional care services. As Missouri implements its primary care health home models, the state will also be working toward the development of a single data portal to facilitate information exchange, measures documentation and calculation and state reporting to CMS. The state will also continue to reţne a process for HIE between CMHCs and primary care practices.
1. HIT for Comprehensive Care Management and Care Coordination – MO HealthNet maintains a web-based electronic health record (EHR) accessible to enrolled Medicaid providers, including primary care practices, CMHCs, and schools. The tool is a HIPAA-compliant portal that enables providers to: a. Download paid claims data submitted for an enrollee by any provider over the past three years (e.g., drug claims, diagnosis codes, CPT codes); b. View dates and providers of hospital emergency department services; c. Identify clinical issues that aſect an enrollee’s care and receive best practice information; d. Prospectively examine how speciţc preferred drug list (PDL) and clinical edit criteria would aſect a prescription for an individual enrollee and determine if a prescription meets requirement for Medicaid payment; e. Electronically request a drug prior authorization or clinical edit override; pre-certiţcations for radiology, durable medical equipment (DME), optical and inpatient services; f. Identify approved or denied drug prior authorizations or clinical edit overrides or medical pre-certiţcations previously issues and transmit a prescription electronically to the enrollee’s pharmacy of choice; and g. Review laboratory data and clinical trait data; h. Determine medication adherence information and calculate medication possession ratios (MPR); and i. Oſer counseling opportunities for pharmacists through a point of service medication therapy management (MTM) module.
2. HIT for Health Promotion and Individual and Family Support Services – A module of the MO HealthNet comprehensive, web-based EHR allows enrollees to access their own healthcare utilization information and receive the same content in laypersons’ terms. The information facilitates self-management and monitoring necessary for an enrollee to attain the highest levels of health and functioning. Primary care health home providers will provide instruction to individuals on the use of the module. Utilization data available through the module includes: a. Administrative claims data for the past three years; b. Cardiac and diabetic risk calculators; c. Chronic health condition information awareness d. A drug information library; and e. The functionality to create a personal health plan and discussion lists to use with healthcare providers. Primary care health home providers are also required to have patient portals in their electronic medical records system which also make various types of information available to enrollees.
3. HIT for Comprehensive Transitional Care – MO HealthNet maintains an initial and concurrent authorization of stay tool which requires hospitals to notify MO HealthNet (via accessing the online authorization tool) within 24 hours of the next usual workday regarding a new admission of any Medicaid enrollee and provide information about diagnosis, condition and treatment for authorization of an inpatient stay. MO HealthNet and the Department of Mental Health have developed a daily process to notify each healthcare home provider of all authorized admissions, which enables the primary care health home provider to: a. Use the hospitalization episode to locate and engage persons in need of primary care health home services; b. Perform the required continuity of care coordination between inpatient and outpatient; and c. Coordinate with the hospital to discharge and avoidable admission as soon as possible.
4. Referral to Community and Social Support Services – Primary care health home providers will be encouraged to monitor continuing Medicaid eligibility using the FSD eligibility website and data base. Primary care health home providers can also access information about impending eligibility lapses (e.g., 60 days in advance).
5. Data Warehouse and Reporting System – The Missouri Primary Care Association maintains a data warehouse for the purpose of functioning as a patient
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registry for the primary care health home providers and generating quality measures to support clinical quality improvement. Patient demographics and clinically authenticated patient care data from the health home EMRs are included in the data set to support the required measures. MPCA also hosts a web-based reporting platform for users. Each health center’s data is available to the health center for individual report generation at all levels, health center, site, provider, and patient, to assist with care management. MPCA generates aggregate reports to support quality improvement, best practice identiţcation, and benchmarking.
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Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID | Medicaid State Plan | Health Homes | MO2018MS0009O | MO-19-0003 | Missouri-2 Health Home Services Package Header Package ID MO2018MS0009O Submission Type OŰcial Approval Date 8/15/2019 Superseded SPA ID 16-0002 User-Entered SPA ID MO-19-0003 Initial Submission Date 6/6/2019 Eſective Date 9/1/2019 Quality Measurement and Evaluation The state provides assurance that all Health Homes providers report to the state on all applicable quality measures as a condition of receiving payment from the state The state provides assurance that it will identify measureable goals for its Health Homes model and intervention and also identify quality measures related to each goal to measure its success in achieving the goals The state provides assurance that it will report to CMS information submitted by Health Homes providers to inform evaluations, as well as Reports to Congress as described in Section 2703(b) of the Aſordable Care Act and as described by CMS The state provides assurance that it will track avoidable hospital readmissions and report annually in the Quality Measures report
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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 0938-1188. The time required to complete this information collection is estimated to average 40 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 8/15/2019 1:38 PM EDT
(spa)(mo-19-0015)(approval-document)Missouri Medicaid SPA MO-19-0015: Approval Document (approved September 23, 2019, effective August 1, 2019)#
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Table of Contents State/Territory Name: MO State Plan Amendment (SPA) #: 19-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Page
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DEPARTMENT OF HEALTH HUMAN SERVICES Centers for Medicare Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106 2898 Kansas City Regional Operations Group September 25, 2019 Jennifer Tidball, Acting Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, MO 65102-1527 Dear Ms. Tidball: On August 29, 2019, the Centers for Medicare & Medicaid Services (CMS) received Missouri’s State Plan Amendment (SPA) transmittal #19-0015. This SPA implemented House Bill 1514 as passed by the General Assembly in June 2019, changing the language from supervising physician to collaborating physician and supervision agreement to collaborative practice agreement for Assistant Physician and Physician Assistant State Plan pages. SPA #19-0015 was approved September 23, 2019, with an effective date of August 1, 2019, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved page for incorporation into the Missouri State Plan. If you have any questions regarding this amendment, please contact Karen Hatcher or Deborah Read at (816) 426-5925. X Enclosure cc: Todd Richardson, Medicaid Director Marissa Crump Nanci Nikodym Leticia Barraza, Acting Director Division of Medicaid Field Operations - North Sincerely,
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DEPARTMENT OF HEALTH AND HUMANSERVICES HEALTli CARE FINANCING /\ DMINJSTRAT! ON TRANSMITIALANDNOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5.TYPE OF PLAN MATERIAL (Check One): I. TRANSMITIAL NUMBER: 19-0015 3. PROGRAM IDENTIFICATION: ORM APPROVE!) 0MB NO 0938 OI9J 2. STATEMissouri TITLE XIX OF THE SOCIAL SECURITY ACT( MEDICAID) 4. PROPOSED EFFECTIVE DATE Aueust 1, 2019 0 NEW STATEPLAN O AMENDMENT TO BE CONSIDERED AS NEW PLAN l2$J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (SeparmeTrammittafforeach a111e11dme111) 6. FEDERAL STATUTE/ REGULATIONCITATION: 42 CFR Part440 8. PAGE NUMBER OF THEPLAN SECTIONORATIACHMENT: Attachment 3.1-A Page 12aa, I0. SUBJECT OF AMENDMENT: 7. PEDERAL BUDGET IMPACT:: i. FFY 2020 $ ...... J) b. FFY 2021 $_ Q 9. PAGE NUMBER OFTHE SUPERSEDES PLAN SECTION OR ATIACHMENT(lfApplicable): Attachment 3.1-A Page 12aa, 12aaa House Bill 1514 passed by the General Assembly in June 2019 changes the language from supervising physician to collaborating physician and changes supervision agreement to collaborative practice agreement on the Assistant Physician and Physician Assistant state plan pages. 11. GOVERNoR·s REVIEW (Check One)
ERNOR' S OFFICEREPORTED NOCOMMEN' 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OFSUBMITIAL 12. SIGNATURE OP STATE AGENCY OFFICIAL: 13. 14. 15. DATE SUBMITTED: D OTHER, AS SPECIFIED: J6: RETURN TO: MO HealthNet Division P.O. Box 6500 JeffersonCity, MO 65 !02 FOR REGIONAL OFFICE USE ONLY 17. DATERECEIVED: I 18: DATE APPROVED: PLAN APPROVED- ONE COPY ATIACHED 19. EFFECTIVEDATE OF APPROVED MATERIAL: 20. SIGNATIJREOFREGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: 12aaa * per state response dated 9.17.19. August 29, 2019 September 23, 2019 August 1, 2019 Leticia Barraza Acting Director Division of Medicaid Field Operations - North, Kansas City
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Attachment 3.1-A Page 12aa State: Missouri 6.d. Other Practitioner's services Physician Assistant Physician Assistant services are covered within their scope of practice defined by state law. Physicians Assistants are supervised by licensed physicians, and collaboration of the Physician Assistant is included in the scope of practice for each collaborating licensed practitioner. Each collaborating licensed practitioner shall assume professional responsibility for the services provided by the Physician Assistant. Assistant Physician Assistant Physician services are covered within their scope of practice defined by state law. Assistant Physicians are supervised by licensed physicians, and collaboration of the Assistant Physician is included in the scope of practice for each collaborating licensed practitioner. Each collaborating licensed practitioner shall assume professional responsibility for the services provided by the Assistant Physician. State Plan TN# 19-0015 Supersedes TN# 18-0023 Effective Date Approval Date Revised Submission 9.17.19 August 1, 2019 September 23, 2019
(spa)(mo-19-0016)(approval-document)Missouri Medicaid SPA MO-19-0016: Approval Document (approved October 10, 2019, effective July 1, 2019)#
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Table of Contents State/Territory Name: MO State Plan Amendment (SPA) #: 19-0016 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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DEPARTMENT OF HEALTH HUMAN SERVICES Centers for Medicare Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106 2898 Kansas City Regional Operations Group October 11, 2019 Jennifer Tidball, Acting Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, MO 65102-1527 Dear Ms. Tidball: On August 1, 2019, the Centers for Medicare & Medicaid Services (CMS) received Missouri’ s State Plan Amendment (SPA) transmittal #19-0016. The purpose of this SPA is to update the fee schedules for MO HealthNet State Plan services due to a 1.5% increase to certain providers as appropriated by the State Legislature. SPA #19-0016 was approved October 10, 2019, with an effective date of July 1, 2019, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Missouri State Plan. If you have any questions regarding this amendment, please contact Karen Hatcher or Deborah Read at (816) 426-5925. Enclosure cc: Todd Richardson, Medicaid Director Amanda Clutter Marissa Crump Glenda Kremer James G. Scott, Director Division of Medicaid Field Operations - North Sincerely,
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August 1, 2019 October 10, 2019 July 1, 2019 James G. Scott Director Division of Medicaid Field Operations - North, Kansas City
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State: Missouri Attachment 4.19 B Page 1 METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES The definition and determination of reasonable charge as administered by the MO HealthNet Division in establishing rates of payment for medical services will be that charge which most nearly reflects the provider's usual and customary charge to the general public for the service, as qualified by application of available prevailing charge resources and the upper and lower limitations of payment stipulated or optionally provided in Federal regulation. If the funds at the disposal or which may be obtained by the MO HealthNet Division for the payment of medical assistance benefits on behalf of any person under one or more of the following specific medical services reimbursement methods, shall at any time become insufficient to pay the full amount thereof, then, pursuant to state law, the amount of any payment on behalf of each of such persons shall be reduced to pro rata in proportion to such deficiency in the total amount available or to become available for such purpose. In accordance with requirements ofTitle 42, Code of Federal Regulations, 447.204, the agency's payments will not be reduced beyond the point at which they become insufficient to enlist enough providers so services under the plan are available to recipients at least to the extent that those services are available to the general population. PHYSICIAN, DENTAL AND PODIATRY SERVICES Physician Services (includes doctors of medicine, osteopathy, podiatry, dentistry). The state agency will establish fee schedules based on the reasonable charge for the services as defined and determined by the MO HealthNet Division. Reimbursement is the lesser of charges or the published fee schedule amount. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of physician, dental and podiatry services. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. The determination and reimbursement of reasonable charge will be in conformance with the standards andmethods as expressed in 42 CFR447Subpart F. Agency payment will be the lower of: 1) The provider's actual charge for the service; or 2) The allowable fee based on reasonable charge as above determined. Payment for physician services for those organ and bone marrow transplant services covered as defined in Attachment 3.1-E will bemade onthe basis of a reasonable charge determination resulting from medical review by the MedicalConsultant. State Plan TN# 19-0016 Supersedes TN# 16 01 Effective Date July 1, 2019 Approval Date Revised Submission 9.25.19 October 10, 2019
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Attachment 4.19 B Page 1b State Plan TN# ___19-0016___ Supersedes TN # __ 10 14 Effective Date July 1, 2019 Approval Date October 10, 2019 STATE: Missouri OPTOMETRIC SERVICES Reimbursement for services is made on a fee-for-service basis. For optometric services including services provided by professional clinics of optometry, the maximum allowable fee for a unit of service has been determined by the MO HealthNet Division to be a reasonable fee, consistent with efficiency, economy, and quality of care. The state payment for each service will be the lower of: 1) The provider’s actual charge for the service; or 2) The Medicaid maximum allowable amount per unit of service. Except as otherwise noted in the plan, state developed fee schedule rates are the same for both public and private providers of optometric services including services provided by professional clinics of optometry. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. The rates are published at: https:// dss.mo.gov/mhd/providers/ pages/ cptagree.htm. Revised Submission 9.5.19
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Attachment 4.19 B Page 2a State Plan TN# 19-0016 Effective Date July 1, 2019 Supersedes TN# 03-20 Approval Date __ ___ OUTPATIENT HOSPITAL SERVICES - OUT-OF-STATE HOSPITALS AND FEDERALLY-OPERATED HOSPITALS LOCATED WITHIN THE STATE OF MISSOURI 1. Out-of-state hospitals shall present claims to Missouri Medicaid within three hundred sixty-five (365) days from the date of service. In no case shall Missouri be liable for payment of a claim received beyond one (1) year from the date services were rendered. Outpatient hospital services must be submitted on the UB-92 claim form. 2. The payment for authorized outpatient hospital services provided by an out-of-state hospital shall be the lowest of: A. At the out-of-state hospital's election, a prospective outpatient payment percentage calculated using the Medicaid over-alt outpatient cost-to-charge ratio from the fourth, fifth, and sixth prior base year cost reports and all documentation required by Missouri regulation for hospitals operating in Missouri regressed to the current state fiscal year or the out-of-state hospital may be exempt from the cost report filing requirement if the hospital accepts the projected statewide average outpatient payment percentage as developed by the Department of Social Services, Division of Medical Services for the state fiscal year in which the service was provided. The effective date for any increase above the statewide average outpatient payment percentage shall be the first day of the month following the Division of Medical Services determination of the outpatient payment percentage based on information from the hospital's Medicare base year cost report and all financial documentation required by Missouri regulation for hospitals operating in Missouri. B. The amount of total charges billed by the hospital. 3. Outpatient Reimbursement Rate Computation. The outpatient reimbursement rate computation is the same as calculated for Missouri hospitals as described in section l. X-RAY SERVICES (INDEPENDENT) The state agency will establish rates for reimbursement which are defined and determined as reasonable by the MO HealthNet Division Payment will be based on the lower of: 1. The provider's actual billed charge, or; 2. The reasonable rate as determined above. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of x-ray services. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at: https:// dss.mo.gov/mhd/providers/pages/ cptagree.htm. LAB SERVICES (INDEPENDENT) The state agency will establish rates for reimbursement which are defined and determined as reasonable by the MO HealthNet Division. The Medicaid fee schedule rates are based on eighty percent (80%) of the current Medicare Clinical Lab Fee Schedule rate using Missouri Locality 01. Payment will be based on the lower of: 1. The provider's actual billed charge, or; 2. The reasonable rate as determined above. Revised Submission 9.5.19 October 10, 2019
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Attachment 4.19 B Page 2b State Plan TN# 19-0016 Effective Date July 1, 2019 Supersedes TN# 15-03 Approval Date State: Missouri Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of lab services. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at: https:// dss.mo.gov/mhd/providers/pages/ cptagree.htm. FAMILY PLANNING The state agency will pay for medical services which are identified as qualified Family Planning services. The payment will be in accordance with the standards and methods herein described as apply to the provider type represented. The state payment for each service will be made on the lower of: 1) The provider's actual charge for the service, or; 2) The maximum allowable fee or rate as determined by the state agency. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Family Planning services. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https:// dss.mo.gov/mhd/providers/pages/ cptagree.htm. EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (E.P.S.D.T.) Reimbursement for EPSDT services provided in accordance with the provisions of section 6403 of PL. 101-239 and federal regulations as promulgated thereunder shall be made on the basis of reasonable allowance fee schedules or per-diem rates, if applicable, as determined by the, state agency, and in accordance with the standards and methods herein described as applicable to the service and provider type represented. The state payment for each service will be made on the lower of: 3) The provider's actual charge for the service, or; 4) The maximum allowable fee or rate as determined by the state agency. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of EPSDT services. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https:// dss.mo.gov/mhd/providers/pages/ cptagree.htm. Reimbursement Methodology for Licensed Behavior Analysts and Licensed Psychologists: A) MO HealthNet shall provide reimbursement to enrolled Licensed Behavior Analysts (LBAs) and Licensed Psychologists ( LPs), who are currently licensed and in good standing with the state, for services provided within their scope of practice. Payment for services rendered by Licensed Assistant Behavior Analysts LABAs) shall be made to the LBA supervising and employing these personnel. Payment for services rendered by technicians shall be made to the LBA or LP supervising and employing these personnel. If the LBA or LP operates through an agency or corporate entity, payment may be made to that agency or entity. Reimbursement for services shall not be made to or for services rendered by a parent, a legal guardian, or other legally responsible person. B) Reimbursement for services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet 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 amount per unit of service. Reimbursement shall only be made for services authorized by MO HealthNet or its designee. C) Except as otherwise noted in the plan, state developed fee schedule rates are the same for both governmental and private providers of ABA services. The agency's fee schedule was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https:// dss.mo.gov/mhd/providers/pages/ cptagree.htm. Revised Submission 9.5.19 October 10, 2019
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Attachment 4.19 B Page 3 State Plan TN# _______19-0016_______ Effective Date _July 1, 2019____ Supersedes TN # _____10-14 _____ Approval Date ______________ State __Missouri___ EMERGENCY AMBULANCE SERVICES Reimbursement for services is made on a fee-for service basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. The state payment for each service will be the lower of: 1. The provider’s actual charge for the services, or; 2. The Medicaid maximum allowable amount per unit of service. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Ambulance services. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at: https:// dss.mo.gov/mhd/providers/ pages/ cptagree.htm. HOME HEALTH SERVICES Reimbursement for services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. The state payment for each service will be the lower of: 1. The provider’s actual charge for the services; or 2. The Medicaid maximum allowable amount per unit of service. Except as otherwise noted in the plan, state developed fee schedule rates are the same for both governmental and private providers of home health program services (intermittent or part-time nursing services, home health aide services, therapy services, and medical supplies). The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at: https:// dss.mo.gov/mhd/providers/ pages/ cptagree.htm . Revised Submission 9.5.19 October 10, 2019
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4.19-B Page 3D State: Missouri Medication Therapy Management (MTM) – Payment to Providers Qualified enrolled pharmacists may be reimbursed for medication therapy management services. Individual qualified pharmacists may be reimbursed for a maximum of 60 minutes of MTM services per month per participant. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of medication therapy management services. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at http:// www.dss.mo.gov/mhd/providers/pages/cptagree.htm . State Plan TN#19-0016 Effective Date July 1, 2019 Supersedes TN#MO 12-20 Approval Date October 10, 2019
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Attachment 4.19 B Revised Submission 10.04.19 Page 4 Rev. 10-2019 State ____________________ Missouri________________________________ Medical Equipment Services The state agency will establish fee schedules based on the reasonable charge for the services as defined and determined by the MO HealthNet Division. Reimbursement is the lesser of charges or the published fee schedule amount. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both public and private providers of Durable Medical Equipment, orthotic and prosthetic devices, rehabilitative training, hearing aids and audiology services. The agency's fee schedule rate was set as of July 1, 2019, and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. The state payment for each service will be the lower of: 1) The provider's actual charge for the service, or; 2) The allowable fee based on reasonable charge as above determined. Ambulatory Surgical Care Clinics The state payment for service will be made on the lower of: 1) The provider's actual charge for the service, or; 2) The Medicaid maximum allowable fee under the established all-inclusive rate. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of ambulatory surgical care clinics. The agency’s fee schedule rate was set as of January 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. Nurse-Midwife Services The state agency will reimburse providers of nurse-midwife services the lower of the provider's usual and customary charge to the general public or the Medicaid maximum allowable amount. For those services reimbursable as nurse-midwife services, the maximum allowable amount will be the same as the physician fees applicable to comparable services. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of nurse midwife services. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. State Plan TN# 19-0016 Effective Date July 1, 2019 Supersedes TN# 10-14 Approval Date October 10, 2019
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Attachment 4.19-B Page 4a State: Missouri Personal Care Services a. Personal Care Services (Agency Model): Reimbursement for services is made on a fee-for-service basis The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. RN supervisory visits provided in Residential Care Facilities are billed by the provider at a separate rate per visit and do not duplicate services already provided by the facility. The state payment for each service shall be the lower of: 1) The provider’s actual charge for the services; or 2) The established rate per service unit or visit as determined by the state agency. The total monthly payment made on behalf of an individual cannot exceed sixty percent (60%) of the average statewide monthly cost for care in a nursing institution (excluding state mental intermediate care facilities). The total monthly payment for personal care for individuals eligible for advanced personal care services may not exceed 100% of the average statewide monthly cost for care in a nursing institution (excluding state mental intermediate care facilities). Except as otherwise noted in the plan, state developed fee schedule rates are the same for both governmental and private providers of personal care services. The agency’s fee schedule rate was set as of July 1, 2019, and is effective for services provided on or after that date. All rates are published at https:// dss.mo.gov/mhd/providers/ pages/cptagree.htm. The fee schedule, as described, applies to all levels of personal care (basic, advanced, and RN supervisory visits). There is a variation in the rates paid according to the setting where services are delivered. The amount of time associated with one unit of basic and advanced Personal Care is 15 minutes. The RN supervisory visit is a per visit unit. Any rate paid for furnishing personal care services to Medicaid beneficiaries does not include a cost consideration for room and board. b. Personal Care Assistance (Consumer-Directed Model) Reimbursement for services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. The total monthly payment for personal care assistance for individuals shall not exceed 60% of the average statewide monthly cost for care in a nursing institution (excluding state mental intermediate care facilities). The State payment for services shall be the lower of: 1) The vendor’s actual charge for the services; or 2) The established rate per service unit as determined by the state agency. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of personal care services. The agency’s fee schedule rate was set as of July 1, 2019, and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. The amount of time associated with one unit of Personal Care Assistance is 15 minutes. The RN supervisory visit is a per visit unit. Any rate paid for furnishing personal care services to Medicaid beneficiaries does not include a cost consideration for room and board. State Plan TN# 19-0016 Effective Date July 1, 2019 Supersedes TN# 11-08 Approval Date: __________ October 10, 2019
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Attachment 4.19 B Page 4aaa Rev. 07/2019 State Missouri Methodestablishingpaymentratesforcasemanagementservicesfordevelopmentallydisabled individuals. For employees of the state, county SB-40 boards, affiliated community service providers, and not-for-profits: The initial uniform prospective hourly fee for case management will be established based on the weighted average hourly cost of all providers as calculated from providers' most recent available cost reports. Cost reports include non-productive time including training time, vacation, holiday and sick leave. The initial calculated fee, which will be based on costs for FY '00, will include an annual and, if appropriate, partial year inflation factor. Annually thereafter until rebasing, on July 1 the previous year's uniform hourly fee will be adjusted by the Consumer Price Index as determined by the Bureau of Labor Statistics or, if available, a Missouri-specific health care index of inflation. The uniform prospective hourly feewill berebased at least once everyten years. For each rebasing year, the uniform prospective hourly fee will be calculated in the same manner as the initial fee described above. The unit of service is 5 minutes with a limit of 240 units per day per participant. The uniform prospective hourly fee is further computed to a 5 minute fee. All providers, statewide, are reimbursed at the same fee. Method for establishing payment rates for case management services for Severely Emotionally Disturbed (SED) children The state agency will reimburse Targeted Case Management providers at fee-for-service rates. The state payment for each service will be the lower of: 1) The provider’s actual charge for the service; or 2) The Medicaid maximum allowable amount per unit of service. A single rate is established for each unit of service. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of rehabilitative services offered by TCM providers (as detailed in Section 3.1-A of the state plan). The TCM procedure codes and the Medicaid fee schedule are published on the MO HealthNet website at https://dss.mo.gov/mhd/providers/fee-for-service- providers.htm and are effective for services provided on or after July 1, 2019. Method for establishing payment rates for case management services for chronically mentally ill adults. The state agency will reimburse Targeted Case Management providers at fee-for-service rates. The state payment for each service will be the lower of: 1) The provider’s actual charge for the service; or 2) The Medicaid maximum allowable amount per unit of service. A single rate is established for each unit of service. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of rehabilitative services offered by TCM providers (as detailed in Section 3.1-A of the state plan). The TCM procedure codes and the Medicaid fee schedule are published on the MO HealthNet website at https://dss.mo.gov/mhd/providers/fee-for-service- providers.htm and are effective for services provided on or after July 1, 2019. State Plan TN# 19-0016 Effective Date 07/01/2019 Supersedes TN# 10-14 Approval Date _________ I 10/10/2019
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Attachment 4. 19- B Page 4d State Missouri Asthma Preventive Education and Counseling for the Participant and In-Home Assessments for Asthma Triggers The state agency shall provide reimbursement for asthma preventive education and counseling and in-home assessments for asthma triggers to enrolled educators and assessors who are currently certified and in good standing with the state as defined in 4b EPSDT Asthma Preventive Education and Counseling for the Participant and In-Home Assessments for Asthma Triggers. Reimbursement for services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee consistent with efficiency, economy, and quality of care. The state payment for each service will be lower of: 1) The provider's actual charge for the services; or 2) The Medicaid maximum allowable amount per unit of service. Reimbursement shall only be made for services authorized by the state agency or it designee. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of asthma preventive education and counseling and in-home assessments for asthma triggers. The agency’s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. State Plan TN# 19- 0016 Effective Date 07/ 01/ 19 Supersedes TN# 16-04 Approval Date Revised Submission 10.09.19 10/10/19
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Attachment 4.19-B Page 4e State Missouri 13.d. Rehabilitative Services Complementary Medicine and Alternatives to Chronic Pain Management The state agency shall provide reimbursement for enrolled providers providing complementary and alternative treatments for chronic pain who are currently in a pending, preliminary, or full recognition status with the Centers for Disease Control and Prevention (CDC), and in good standing with the state as defined in 13 CSR 70-3.290. Complementary Medicine and Alternative Pain Management for adults is a structured program developed to decrease use and misuse of opioid medications along with providing alternative treatments for chronic pain. Reimbursement for services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. The state payment for each service will be the lower of: 1) The provider's actual charge for the services; or 2) The Medicaid maximum allowable amount per unit of service. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Complementary Medicine and Alternatives to Chronic Pain Management. The agency's fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. State Plan # 19-0016 Effective Date July 1, 2019 Supersede 18-0007 Approval Date Revised Submission 10.09.19 October 10, 2019
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Attachment 4.19-B Page 4f State Missouri 6.d. Other Licensed Practitioner Acupuncturists Reimbursement for services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. The state payment for each service will be the lower of: 1) The provider's actual charge for the services; or 2) The Medicaid maximum allowable amount per unit of service. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of acupuncture services. The agency's fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. 6.d.(b) Other Licensed Practitioner Chiropractors Reimbursement for services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. The state payment for each service will be the lower of: 1) The provider's actual charge for the services; or 2) The Medicaid maximum allowable amount per unit of service. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of chiropractic services. The agency's fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. State Plan # 19-0016 Effective Date July 1, 2019 Supersede 18-0007 Approval Date Revised Submission 10.09.19 October 10, 2019
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4. 19- B Rev. 7/ 19 Page 5 State Missouri Community Psychiatric Rehabilitation Services Thestate agency willreimburse Community Psychiatric Rehabilitation Services providersatfee-for-servicerates. Thestate payment for each service will be the lower of: 1) The provider' s actual charge for the service; or 2) The Medicaid maximum allowable amount per unit of service. A single rate is established for each unit of service. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of rehabilitative services offered by CPR providers ( as detailed in Section 3. 1- A of the state plan). The CPR procedure codes and the Medicaid fee schedule are published on the MO HealthNet website at https:// dss. mo. gov/ mhd/ providers/ fee-for-service- providers. htm and are effective for services provided on or after July 1, 2019. State Plan TN# 19- 0016 Effective Date 7/ 1/ 19 Supersedes TN# 89- 6 Approval Date _______ 10/10/19
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State Missouri Attachment 4.19-B Rev. 07/19 Page 6 Comprehensive Day Rehabilitation Services 1) Reimbursement for Comprehensive Day Rehabilitation Services is by the fee schedule, at the lesser of the bi11ed charge or the MO HealthNet maximum allowable fee per unit. The daily reimbursement rate is one unitof Comprehensive Day Rehabilitation Services which is defined as either one-half day (three to four hours) or one day (five or more hours). 2) Reimbursement is a half-day or daily rate based on the participant's level of care. A participant's level of care is based on the assessment to determine eligibility for the program. The MMIS will assure a half-day and a daily rate are not paid on the same date of service, and will also assure only one unit of either half-day or full-day is paid per date of service per participant. 3) Comprehensive day rehabilitation services must be prior authorized and cover a combination of goal oriented rehabilitation services provided by multiple providers according to a multiple hour schedule over a week's time, Services are designed to maintain andimprove the recipient's ability tofunction asindependently as possible inthe community. Servicesareprovided at a free-standing rehabilitation center. Services must include: an evaluation/assessment todetermine whether comprehensive day rehabilitation services are appropriate for the recipient; development of an individualized plan ofcare; services that address independent livingskills and basic self care needs; a service package that requires services from at least three of the following professionals: o psychologist/neuropsychologist · · o speech/language therapist o physical therapist o occupational therapist o vocational rehabilitation specialist o education specialist o recreational therapist o counselor o casemanager Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Comprehensive Day Rehabilitation services. The agency’ s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. State Plan TN# 19-0016 Supersedes TN # 11-03 Effective Date July 1, 2019 Approval Date October 10, 2019
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EPSDT Lead Environmental Assessment Provider Attachment 4.19-B Rev. 06/19 Page 6c The state agency will establish fee schedules based on the reasonable charge for the services as defined and determined by the MO HealthNet Division. Agency payment will be the lower of: 1. The provider's actual charge for the service; or 2. The allowable fee based on reasonable charge as above determined Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of EPSDT Lead Environmental Assessment Providers. The agency's fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. State Plan TN# 19-0016 Supersedes TN# 11-03 Effective Date July 1, 2019 Approval Date October 10, 2019
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Attachment 4.19-B Revised Submission 9.25.19 Page 9 State Missouri Nurse Practitioner/Clinical Nurse Specialist Services The state agency will establish fee schedules based on the reasonable charge for the services as defined and determined by the MO HealthNet Division. Agency payment will be the lower of: 1) The provider’s actual charge for the service; or 2) The allowable fee based on reasonable charge as above determined. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of nurse practitioner/clinical nurse specialist services. The agency’ s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at http://www.dss.mo.gov/mhd/providers/pages/cptagree/htm Licensed Psychologist’s, School Psychologist’ s, Licensed Professional Counselor’s, Licensed Clinical Social Worker’ s, and Licensed Marital and Family Therapist’s Services The state agency will establish fee schedules based on the reasonable charge for the services as defined and determined by the MO HealthNet Division. Reimbursement in the lesser of charges or the published fee schedule amount. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of psychological services. The agency’ s fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at http://www.dss.mo.gov/mhd/providers/pages/cptagree/htm State Plan TN # 19-0016 Effective Date – July 1, 2019 Supersedes TN # 17- 001 Approval Date - _______ October 10, 2019
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Revised Submission 09.25.19 State - Missouri Attachment 4.19 B Page 9a Anesthesiologist Assistant Services The state agency will establish fee schedules based on the reasonable charge for the services as defined and determined by the Division of Medical Services. The determination and reimbursement of reasonable charge will be in conformance with the standards and methods as expressed in 42 CFR 447 Subpart F. The Agency payment will be the lower of: 1) The provider's actual charge for the service; or 2) The Medicaid allowable reimbursement for the service. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of anesthesiologist assistant services. The agency's fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/providers/pages/cptagree.htm. State Plan TN# . 19-0016 Supersedes TN.# 05-10 Effective Date July 1. 2019 Approval Date October 10, 2019
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State: Missouri Attachment 4.19 B Page 9aa PHYSICIAN ASSISTANT SERVICES Except as otherwise noted in the plan, state developed fee schedule rates are the same for both public and private providers of physician assistant services. The agency's fee schedule rate was set as of July 1, 2019, and is effective for services provided on or after that date. All rates are published at https://dss.mo.qov/mhd/providers/pages/cptagree.htm. ASSISTANT PHYSICIAN SERVICES Except as otherwise noted in the plan, state developed fee schedule rates are the same for both public and private providers of assistant physician services. The agency's fee schedule rate was set as of July 1, 2019, and is effective for services provided on or after that date. All rates are published at https://dss.mo.gov/mhd/provlders/pages/cptagree.htm. State Plan TN# 19-0016 Supersedes TN# 18 0023 Effective Date July 1, 2019 Approval Date Revised Submission 10.09.19 October 10, 2019
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Attachment 4.19-B Page 18a State: Missouri Independent Clinics Services provided by Independent Clinics shall be reimbursed at the lower of the following: 1.Submitted charges; or2. Fee schedule as determined by the MOHealthNet Division Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of independent clinic services. The agency's fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at http://www.dss.mo.gov/mhd/providers/index.htm. Public Health Clinics Services provided by Public Health Clinics shall be reimbursed at the lower of the following: 1. Submitted charges; or2. Fee schedule as determined by the MOHealthNet Division Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of public health clinic services. The agency's fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at http://www.dss.mo.gov/mhd/providers/index.htm. Community Mental Health Clinics Servicesprovided byCommunity Mental Health Clinics (CMHC) shallbereimbursed at the lowerof the following: 1. Submitted charges; or 2. Fee schedule as determined by the MO HealthNetDivision Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of CMHC services. The agency's fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at http://www.dss.mo.gov/mhd/providers/index.htm. Planned Parenthood Clinics Services provided by Planned Parenthood Clinics shall bereimbursed at the lower of the following: 1. Submitted charges or 2. Fee schedule asdetermined bythe MOHealthNet Division Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Planned Parenthood clinic services. The agency's fee schedule rate was set as of July 1, 2019 and is effective for services provided on or after that date. All rates are published at http://www.dss.mo.gov/mhd/providers/index.htm. State Plan TN#._19-0016 Effective Date 07/01/2019_ Supersedes TN# 10-14 Approval Date 10/10/2019
(spa)(mo-19-0017)(approval-document)Missouri Medicaid SPA MO-19-0017: Approval Document (approved November 3, 2019, effective July 1, 2019)#
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Table of Contents State/Territory Name: MO State Plan Amendment (SPA) #: 19-0017 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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Records / Submission Packages MO - Submission Package - MO2019MS0003O - (MO-19-0017) - Health Homes CMS-10434 OMB 0938-1188 Package Information Package ID MO2019MS0003O Program Name Migrated_HH.Community Mental Health Center – Health Homes SPA ID MO-19-0017 Version Number 3 Submitted By Marissa Crump Package Disposition Priority Code P2 Submission Type Official State MO Region Kansas City, KS Package Status Approved Submission Date 9/26/2019 Approval Date 11/13/2019 3:19 PM EST Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions Page 1 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Kansas City Regional Office 601 E. 12th Street, Suite 355 Kansas City, MO 64106 Division of Medicaid and Children's Health Operations November 13, 2019 Todd Richardson Director MO HealthNet Division 615 Howerton Court Jefferson City, MO 65109 Re: Approval of State Plan Amendment MO-19-0017 Migrated_HH.Community Mental Health Center – Health Homes Dear Todd Richardson: On September 26, 2019, the Centers for Medicare and Medicaid Services (CMS) received Missouri State Plan Amendment (SPA) MO-19-0017 for Migrated_HH.Community Mental Health Center – Health Homes to add a 1.5% rate increase to the PMPM for CMHC Health Homes. We approve Missouri State Plan Amendment (SPA) MO-19-0017 on November 13, 2019 with an effective date(s) of July 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact Karen Hatcher at karen.hatcher@cms.hhs.gov. Sincerely, James Scott Division of Medicaid Field Operations - North Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date N/A State Information State/Territory Name: Missouri Medicaid Agency Name: MO HealthNet Division Submission Component State Plan Amendment Medicaid CHIP Page 2 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date N/A SPA ID and Effective Date SPA ID MO-19-0017 Reviewable Unit Proposed Effective Date Superseded SPA ID Health Homes Intro 7/1/2019 16-0007 Health Homes Geographic Limitations 7/1/2019 16-0007 Health Homes Population and Enrollment Criteria 7/1/2019 16-0007 Health Homes Providers 7/1/2019 16-0007 Health Homes Service Delivery Systems 7/1/2019 16-0007 Health Homes Payment Methodologies 7/1/2019 16-0007 Health Homes Services 7/1/2019 16-0007 Health Homes Monitoring, Quality Measurement and Evaluation 7/1/2019 16-0007 Page 3 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives SPA 19-0017 adds a 1.5% rate increase to the PMPM for CMHC Health Homes effective July 1, 2019. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $17000 Second 2020 $204000 Federal Statute / Regulation Citation Section 2703 of the Affordable Care Act and Section 1945 of the Social Security Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Page 4 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Page 5 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Public Notice/Process MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date N/A Name of Health Homes Program Migrated_HH.Community Mental Health Center – Health Homes Public notice was provided due to proposed changes in methods and standards for setting payment rates for services, pursuant to 42 CFR 447.205. Upload copies of public notices and other documents used Name Date Created PublicNoticeFY20RateIncrease 8/21/2019 12:43 PM EDT Page 6 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Tribal Input MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date N/A Name of Health Homes Program: Migrated_HH.Community Mental Health Center – Health Homes One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No Page 7 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Other Comment MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date N/A SAMHSA Consultation Name of Health Homes Program Migrated_HH.Community Mental Health Center – Health Homes The State provides assurance that it has consulted and coordinated with the Substance Abuse and Mental Health Services Administration (SAMHSA) in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions. Date of consultation 2/28/2011 Page 8 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Intro MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Program Authority 1945 of the Social Security Act The state elects to implement the Health Homes state plan option under Section 1945 of the Social Security Act. Name of Health Homes Program Migrated_HH.Community Mental Health Center – Health Homes Executive Summary Provide an executive summary of this Health Homes program including the goals and objectives of the program, the population, providers, services and service delivery model used Data conversion from previous Medicaid Model Data Lab. Supersedes Transmittal Number:00-0000 Transmittal Number:11-0011 This State Plan Amendment is in Attachment 3.1-H of the State Plan, except for the Payment Methodologies section, which is in Attachment 4.19-B (48) of the State Plan. General Assurances The state provides assurance that eligible individuals will be given a free choice of Health Homes providers. The states provides assurance that it will not prevent individuals who are dually eligible for Medicare and Medicaid from receiving Health Homes services. The state provides assurance that hospitals participating under the state plan or a waiver of such plan will be instructed to establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated Health Homes providers. The state provides assurance that FMAP for Health Homes services shall be 90% for the first eight fiscal quarters from the effective date of the SPA. After the first eight quarters, expenditures will be claimed at the regular matching rate. The state provides assurance that it will have the systems in place so that only one 8-quarter period of enhanced FMAP for each health homes enrollee will be claimed. The state provides assurance that there will be no duplication of services and payment for similar services provided under other Medicaid authorities. Page 9 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Geographic Limitations MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Health Homes services will be available statewide Health Homes services will be limited to the following geographic areas Health Homes services will be provided in a geographic phased-in approach Page 10 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Categories of Individuals and Populations Provided Health Homes Services The state will make Health Homes services available to the following categories of Medicaid participants Categorically Needy (Mandatory and Options for Coverage) Eligibility Groups Medically Needy Eligibility Groups Page 11 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Population Criteria The state elects to offer Health Homes services to individuals with: Two or more chronic conditions Specify the conditions included: Mental Health Condition Substance Use Disorder Asthma Diabetes Heart Disease BMI over 25 Other (specify): Name Description Developmental disability CMHCs will be the state’s designated provider for individuals of any age with: • Developmental disability: this term is used as defined in section 630.005(9) of the Revised Statutes of Missouri. • Chronic Obstructive Pulmonary Disorder: changes in the lungs and airways that impede the flow of air, including emphysema and chronic bronchitis. One chronic condition and the risk of developing another Specify the conditions included: Mental Health Condition Substance Use Disorder Asthma Diabetes Heart Disease BMI over 25 Other (specify): Name Description Developmental Disability Developmental disability: this term is used as defined in section 630.005(9) of the Revised Statutes of Missouri. Page 12 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Specify the criteria for at risk of developing another chronic condition: Description of “At Risk” Criteria: 1.Tobacco use (tobacco use is considered an at-risk behavior for chronic conditions such as asthma and CVD). 2.Diabetes (Diabetes is considered an at-risk behavior for chronic conditions such as CVD and BMI over 25). CMHCs will be the state’s designated provider for individuals of any age with: • Developmental disability: this term is used as defined in section 630.005(9) of the Revised Statutes of Missouri. • Chronic Obstructive Pulmonary Disorder: changes in the lungs and airways that impede the flow of air, including emphysema and chronic bronchitis (The description below is a continuation of the "criteria for a serious and persistent mental health condition" that was started in the box below) 10. Anxiety Disorders A. Generalized Anxiety Disorder B. Panic Disorder with Agoraphobia C. Panic Disorder without Agoraphobia D. Agoraphobia without Panic Disorder E. Social Phobia 11. For children and youth only A. Major depressive disorder, single episode B. Bipolar C. Reactive attachment disorder of infancy or early childhood 12. For adults aged sixty (60) years and over A. Major depressive disorder, single episode 13. Adults with a DLA-20© mGAF score of 40 or lower, in combination with one of the following DSM diagnoses, meet the disability and diagnostic requirements: A. Bipolar Disorder, Most Recent Episode Unspecified B. Shared Psychiatric Disorder C. Conversion Disorder D. Dissociative Identity Disorder E. Dysthymic Disorder F. Depersonalization Disorder G. Body Dysmorphic Disorder H. Hypochondriasis I. Somatization Disorder J. Undifferentiated Somatoform Disorder K. Paranoid Personality Disorder L. Cyclothymic Disorder M. Schizoid Personality Disorder N. Schizotypal Personality Disorder O. Obsessive-Compulsive Personality Disorder P. Histrionic Personality Disorder Q. Dependent Personality Disorder R. Antisocial Personality Disorder S. Narcissistic Personality Disorder T. Avoidant Personality Disorder U. Personality Disorder NOS V. Pain Disorder Associated with Psychological Factors W. Pain Disorder Associated with Both Psychological Factors and a General Medical Condition X. Intermittent Explosive Disorder 14. Individuals younger than 18 with a DLA-20© mGAF or CGAS score of 50 or lower, in combination with the following DSM psychiatric diagnoses, meet the disability and diagnostic requirements: A. Any diagnosis listed above, or B. Separation Anxiety Disorder C. Oppositional Defiant Disorder D. Attention-Deficit/Hyperactivity Disorder (Predominantly Inattentive Type, Predominantly Hyperactive-Impulsive Type, Combined Type) 15. Youth or adults, meeting the age-appropriate DLA-20© mGAF or CGAS score requirements and who have one of the following Not Page 13 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Otherwise Specified (NOS) Disorders, also meet the disability and diagnostic requirements. When an NOS disorder is used as the diagnosis, documentation must specifically include a detailed history/examination for each of the non-NOS criteria and a clear rationale for how those criteria are not met, thus supporting the appropriateness of an NOS diagnosis. A. Mood Disorder NOS B. Anxiety Disorder NOS C. Dissociative Disorder NOS D. Personality Disorder NOS E. Depressive Disorder NOS F. Impulse Control Disorder NOS G. Disruptive Behavior Disorder NOS H. AD/HD NOS I. Bipolar Disorder NOS • Duration. Rehabilitation services shall be provided to those individuals whose mental illness is of sufficient duration as evidenced by one (1) or more of the following occurrences: 1. Persons who have undergone psychiatric treatment more intensive than outpatient more than once in a lifetime (crisis services, alternative home care, partial hospital, inpatient); 2. Persons who have experienced an episode of continuous residential care other than hospitalization, for a period long enough to disrupt the normal living situation; 3. Persons who have exhibited the psychiatric disability for one (1) year or more; or 4. Persons whose treatment of psychiatric disorders has been or will be required for longer than six (6) months; • A functional assessment may be used to establish eligibility and the need for and amount of services, including results from a standardized assessment prescribed by the department; and • Whenever discrepancies occur regarding the appropriateness of an ICD-10-CM versus a DSM diagnosis, the DSM diagnosis shall prevail. One serious and persistent mental health condition Specify the criteria for a serious and persistent mental health condition: In Missouri, ‘Serious and Persistent Mental Health Condition’ is labeled ‘Serious Mental Illness’ (SMI). SMI is defined by disability, diagnosis, and duration; which are outlined below: • Disability. There shall be clear evidence of serious and/or substantial impairment in the ability to function at an age or developmentally-appropriate level due to serious psychiatric disorder in each of the following two (2) areas of behavioral functioning, as indicated by intake evaluation and assessment: o Social role functioning/family life— the ability to sustain functionally the role of worker, student, homemaker, family member, or a combination of these; and o Daily living skills/self-care skills— the ability to engage in personal care (such as grooming, personal hygiene) and community living (handling individual finances, using community resources, performing household chores), learning ability/self-direction, and activities appropriate to the individual’s age, developmental level, and social role functioning; • Diagnosis. A physician or licensed psychologist shall certify a primary Diagnostic and Statistical Manual (DSM) diagnosis using the current edition of the manual. This diagnosis may coexist with other psychiatric diagnoses. 1. Schizophrenia A. Disorganized B. Catatonic C. Paranoid D. Schizophreniform E. Residual F. Schizoaffective G. Undifferentiated 2. Delusional disorder 3. Bipolar I disorders A. Single manic episode B. Most recent episode manic C. Most recent episode depressed D. Most recent episode mixed 4. Bipolar II disorders Page 14 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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5. Psychotic disorders NOS 6. Major depressive disorder-recur 7. Obsessive-Compulsive Disorder 8. Post-Traumatic Stress Disorder 9. Borderline Personality Disorder (This description is continued above in the box for "Additional description of other chronic conditions") Page 15 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Population and Enrollment Criteria MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Enrollment of Participants Participation in a Health Homes is voluntary. Indicate the method the state will use to enroll eligible Medicaid individuals into a Health Home: Opt-In to Health Homes provider Referral and assignment to Health Homes provider with opt-out Other (describe) Describe the process used: Individuals eligible for Health Home services and identified by the state as being existing service users of a Health Home will be auto- assigned to eligible providers based on qualifying conditions. Upon enrollment, individuals assigned to a Health Home will be informed by the state via U.S. mail and other methods as necessary of all available Health Homes throughout the state. The notice will describe individuals’ choice in selecting a Health Home as well as provide a brief description of Health Home services, and describe the process for individuals to opt-out of receiving treatment services from the assigned Health Home provider. Individuals who have been auto- assigned to a Health Home provider will have the choice to opt out of receiving treatment services from the assigned Health Home provider and select another service provider from the available Health Homes throughout the state at any time. Individuals who have been auto- assigned to a Health Home provider may also opt out of the Health Home program altogether at any time without jeopardizing their existing services. Other individuals with qualifying chronic conditions who are not currently receiving services at the Health Home may request to be part of the Health Home. Potentially eligible individuals receiving services in the hospital ED or as an inpatient will be notified about eligible Health Homes and referred based on their choice of provider. Eligibility for Health Home services will be identifiable through the state’s comprehensive Medicaid electronic health record. Health Home providers to which patients have been auto-assigned will receive communication from the state regarding a patient’s enrollment in Health Home services. The Health Home will notify other treatment providers (e.g., primary care and specialists such as OB/GYN) about the goals and types of Health Home services as well as encourage participation in care coordination efforts. The state provides assurance that it will clearly communicate the individual's right to opt out of the Health Homes benefit or to change Health Homes providers at any time and agrees to submit to CMS a copy of any letter or communication used to inform the individuals of the Health Homes benefit and their rights to choose or change Health Homes providers or to elect not to receive the benefit. Name Date Created HCH Opt Out Letter Sept 2019 9/16/2019 12:17 PM EDT Page 16 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Providers MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Types of Health Homes Providers Designated Providers Indicate the Health Homes Designated Providers the state includes in its program and the provider qualifications and standards Physicians Clinical Practices or Clinical Group Practices Rural Health Clinics Community Health Centers Community Mental Health Centers Describe the Provider Qualifications and Standards CMHCs will serve as designated providers of Health Home services. All designated providers will be required to meet state qualifications. CMHCs are certified and designated by the Department of Mental Health and provide services through a statewide catchment area arrangement. The Missouri CMHC catchment area system divides the state into separate catchment areas. Each catchment area has the specific responsibility of one or more CMHCs. Home Health Agencies Case Management Agencies Community/Behavioral Health Agencies Federally Qualified Health Centers (FQHC) Other (Specify) Teams of Health Care Professionals Health Teams Provider Infrastructure Describe the infrastructure of provider arrangements for Health Home Services CMHCs will serve as designated providers of Health Home services. All designated providers will be required to meet state qualifications. CMHCs are certified and designated by the Department of Mental Health and provide services through a statewide catchment area arrangement. The Missouri CMHC catchment area system divides the state into separate catchment areas. Each catchment area has the specific responsibility of one or more CMHCs (three CMHCs are assigned more than one catchment area), assuring statewide and complete coverage of all catchment areas. CMHC Health Homes will be physician-led with an individual’s multi-disciplinary team minimally comprised of the individual’s treating psychiatrist, qualified mental health professional, mental health case manager, and nurse care manager. Additional multi-disciplinary team members may include an individual’s treating primary care physician, as well as other representatives as appropriate to meet client needs (e.g. educational, employment, or housing representatives). All members of an individual’s team will be responsible for ensuring that care is person- centered, culturally competent and linguistically capable. In addition, CMHC Healthcare Homes will include a Health Home Director, Primary Care Physician Consultant, and Care Coordinator/Clerical Support staff. The Health Home Director is responsible for championing practice transformation designed to integrate physical and behavioral health and wellness; managing health home enrollments, discharges, and Page 17 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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transfers; overseeing the daily operations of the health home, including overseeing the development, and submission, of required monthly health home reports to the State; and, if appropriately credentialed, participating in health education activities. The Primary Care Physician Consultant establishes organizational priorities for disease management and improving health status; participates in case consultation with multi-disciplinary teams; helps educate clinical staff on the nature, course, and treatment of chronic diseases; and develops collaborative relationships between the organization and treating Primary Care Physicians, between treating Primary Care Physicians and Psychiatrists,, and between the organization and other healthcare professionals and facilities. The care coordinator/clerical support staff facilitates the multi- disciplinary teams’ reviews of monthly care management and hospital admission reports; completes metabolic screening data entry; assists with appointment scheduling and client tracking; provides technical assistance to the multi-disciplinary teams in utilizing the automated care management reporting systems; and may, if appropriately credentialed, at the request of a multi-disciplinary team, assist in providing case management services. The cost of the Nurse Care Manager, Health Home Director, Primary Care Physician Consultant, and Care Coordinator/Clerical Support staff will be covered by the PMPM rate described in the Payment Methodology section below. CMHCs will be supported in transforming service delivery by participating in statewide learning activities. Given CMHCs’ varying levels of experience with practice transformation approaches, the State will assess providers to determine learning needs. CMHCs will therefore participate in a variety of learning supports, up to and including learning collaboratives, specifically designed to instruct CMHCs to operate as Health Homes and provide care using a whole person approach that integrates behavioral health, primary care and other needed services and supports. Learning activities will be supplemented with periodic calls to reinforce the learning sessions, practice coaching, and monthly practice reporting (data and narrative) and feedback. Supports for Health Homes Providers Describe the methods by which the state will support providers of Health Homes services in addressing the following components 1. Provide quality-driven, cost-effective, culturally appropriate, and person- and family- centered Health Homes services 2. Coordinate and provide access to high quality health care services informed by evidence-based clinical practice guidelines 3. Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders 4. Coordinate and provide access to mental health and substance abuse services 5. Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care 6. Coordinate and provide access to chronic disease management, including self-management support to individuals and their families 7. Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services 8. Coordinate and provide access to long-term care supports and services 9. Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health- care related needs and services 10. Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate 11. Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level Description CMHCs will be supported in transforming service delivery by participating in statewide learning activities. Given CMHCs’ varying levels of experience with practice transformation approaches, the State will assess providers to determine learning needs. CMHCs will therefore participate in a variety of learning supports, up to and including learning collaboratives, specifically designed to instruct CMHCs to operate as Health Homes and provide care using a whole person approach that integrates behavioral health, primary care and other needed services and supports. Learning activities will be supplemented with periodic calls to reinforce the learning sessions, practice coaching, and monthly practice reporting and feedback. Other Health Homes Provider Standards The state's requirements and expectations for Health Homes providers are as follows Initial Provider Qualifications 1. State Qualifications: In addition to being a state-designated CMHC, each Health Home provider must meet state qualifications, which may be amended from time-to-time as necessary and appropriate, but minimally require that each Health Home: a. Have a substantial percentage of its patients enrolled in Medicaid, with special consideration given to those with a considerable volume of needy individuals, defined as receiving medical assistance from Medicaid or the Children’s Health Insurance Program (CHIP), furnished uncompensated care by the provider, or furnished services at either no cost or reduced based on a sliding scale. Patient percentage requirements will be determined by the state; b. Have strong, engaged leadership personally committed to and capable of leading the practice through the transformation process and sustaining transformed practice processes as demonstrated through the application process and agreement to participate in learning activities including in-person sessions and regularly scheduled phone calls; and that agency leadership have presented the state approved “Paving the Way for Health Care Homes” PowerPoint introduction to Missouri’s Health Home Initiative to all agency staff and board of directors; c. Meet state requirements for patient empanelment (i.e., each patient receiving CMHC health home services must be assigned to a physician); d. Meet the state’s minimum access requirements as follows: Prior to implementation of health home service coverage, provide assurance of enhanced patient access to the health team, including the development of alternatives to face-to-face visits, such as telephone or email, 24 hours per day 7 days per week; e. Actively use MO HealthNet’s comprehensive electronic health record (EHR) to conduct care coordination and prescription monitoring for Medicaid participants; f. Utilize an interoperable patient registry to input annual metabolic screening results, track and measure care of individuals, automate care Page 18 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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reminders, and produce exception reports for care planning; g. Routinely use a behavioral pharmacy management system to determine problematic prescribing patterns; h. Conduct wellness interventions as indicated based on clients’ level of risk; i. Complete status reports to document clients’ housing, legal, employment status education, custody etc.; j. Agree to convene regular, ongoing and documented internal Health Home team meetings to plan and implement goals and objectives of practice transformation; k. Agree to participate in CMS and state-required evaluation activities; l. Agree to develop required reports describing CMHC Health Home activities, efforts and progress in implementing Health Home services (e.g., monthly clinical quality indicators reports utilizing clinical data in disease registries, breakdown of Primary Care Nurse Manager’s time and activities); m. Maintain compliance with all of the terms and conditions as a CMHC Health Home provider or face termination as a provider of CMHC Health Home services; and n. Present a proposed Health Home delivery model that the state determines to have a reasonable likelihood of being cost-effective. Cost effectiveness will be determined based on the size of the Health Home, Medicaid caseload, percentage of caseload with eligible chronic conditions of patients and other factors to be determined by the state. 2. Ongoing Provider Qualifications Each CMHC must also: a. Within 3 months of Health Home service implementation, have developed a contract or MOU with regional hospital(s) or system(s) to ensure a formalized structure for transitional care planning, to include communication of inpatient admissions of Health Home participants, as well as maintain a mutual awareness and collaboration to identify individuals seeking ED services that might benefit from connection with a Health Home site, and in addition motivate hospital staff to notify the CMHC Primary Care Nurse Manager or staff of such opportunities. The state will assist in obtaining hospital/Health Home MOU if needed; b. Develop quality improvement plans to address gaps and opportunities for improvement identified during and after the application process; c. Demonstrate continuing development of fundamental health home functionality at 6 months and 12 months through an assessment process to be applied by the state; d. Demonstrate significant improvement on clinical indicators specified by and reported to the state; e. Provide a Health Home that demonstrates overall cost effectiveness; and f. Meet NCQA level 1 PCMH requirements as determined by a DMH review or submit an application for NCQA recognition by month 18 from the date at which supplemental payments commence OR meet equivalent recognition standards approved by the state as such standards are developed. Name Date Created No items available Health Homes Service Delivery Systems MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Identify the service delivery system(s) that will be used for individuals receiving Health Homes services Fee for Service PCCM Risk Based Managed Care Other Service Delivery System Page 19 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Payment Methodology The State's Health Homes payment methodology will contain the following features Fee for Service Individual Rates Per Service Per Member, Per Month Rates Fee for Service Rates based on Severity of each individual's chronic conditions Capabilities of the team of health care professionals, designated provider, or health team Other Comprehensive Methodology Included in the Plan Incentive Payment Reimbursement Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided All CMHC Health Home providers will receive the same PMPM rate. PCCM (description included in Service Delivery section) Risk Based Managed Care (description included in Service Delivery section) Alternative models of payment, other than Fee for Service or PMPM payments (describe below) Page 20 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Agency Rates Describe the rates used FFS Rates included in plan Comprehensive methodology included in plan The agency rates are set as of the following date and are effective for services provided on or after that date Page 21 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Rate Development Provide a comprehensive description in the SPA of the manner in which rates were set 1. In the SPA please provide the cost data and assumptions that were used to develop each of the rates 2. Please identify the reimbursable unit(s) of service 3. Please describe the minimum level of activities that the state agency requires for providers to receive payment per the defined unit 4. Please describe the state's standards and process required for service documentation, and 5. Please describe in the SPA the procedures for reviewing and rebasing the rates, including • the frequency with which the state will review the rates, and • the factors that will be reviewed by the state in order to understand if the rates are economic and efficient and sufficient to ensure quality services. Comprehensive Description Rate Basis/Development Overview of Payment Structure: Missouri has developed the following payment structure for designated CMHC Health Homes. All payments are contingent on the Health Home meeting the requirements set forth in their Health Home applications, as determined by the State of Missouri. Failure to meet such requirements is grounds for revocation of Health Home status and termination of payments. Clinical Care Management per-member-per-month (PMPM) payment: Cost Assumptions/Factors Used to Determine Payment Missouri will pay CMHC health homes the cost of staff primarily responsible for delivery of services not covered by other reimbursement (Primary Care Nurses, Physician Consultants, and Administrative Support staff) whose duties are not otherwise reimburseable by MO HealthNet. Homes receive payments related to Health Home specific training, technical assistance, administration, and data analytics. • Staff cost is based on a provider survey of all CMHCs statewide and includes fringe, operating & indirect costs. • All CMHC Health Home providers will receive the same PMPM rate. • The PMPM method will be reviewed periodically to determine if the rate is economically efficient and consistent with quality of care. Clinical Care Management Standards Managed Care: All Health Home payments including those for MO HealthNet (“MHN”) participants enrolled in managed care plans will be made directly from MHN to the Health Home provider. As a result of the additional value that managed care plans will receive from MHN direct paid Health Home services, the managed care plan is not required to provide care coordination or case management services that would duplicate the CMS reimbursed health home services. This Health Home delivery design and payment methodology will not result in any duplication of payment between Health Homes and managed care. The managed care plan will be informed of its members that are in Health Home services and a managed care plan contact person will be provided for each Health Home provider to allow for coordination of care. • The managed care plan will be required to inform either the individual’s Health Home or MO Health Net of any inpatient admission or discharge of a Health Home member that the plan learns of through its inpatient admission initial authorization and concurrent review processes within 24 hours. • The CMHC Health Home team will provide Health Home services in collaboration with MCO network primary care physicians in the same manner as they will collaborate with any other primary care physician who is serving as the PCP of an individual enrolled in the CMHC Health Home. Minimum Criteria for Payment: The criteria required for receiving the PMPM payment is: A. The person is identified as meeting CMHC health home eligibility criteria on the State-run health home patient registry; B. The person is enrolled as a health home member at the billing health home provider and is enrolled in only one health home at a time; C. The minimum health home service required to merit payment of the PMPM is that the person has received Care Management monitoring for treatment gaps; or another health home service was provided that was documented; and D. The health home will report that the minimal service required for the PMPM rate payment occurred on a monthly health home attestation report. Except as otherwise noted in the plan, state-developed per-member-per-month rates are the same for both Page 22 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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governmental and private providers of health home services. The agency’s per-member-per-month rate is published on the website at: https://dmh.mo.gov/media/pdf/cmhc-hch-pmpm-rate-chart and is effective for services provided on or after July 1, 2019. Page 23 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Assurances The State provides assurance that it will ensure non-duplication of payment for services similar to Health Homes services that are offered/covered under a different statutory authority, such as 1915(c) waivers or targeted case management. Describe below how non- duplication of payment will be achieved Health Home service payments will not result in any duplication of payment or services between Medicaid programs, services, or benefits (i.e. managed care, other delivery systems including waivers, any future Health Home state plan benefits, and other state plan services). In addition to offering guidance to providers regarding this restriction, the State may periodically examine recipient files to ensure that Health Home participants are not receiving similar services through other Medicaid-funded programs. The state has developed payment methodologies and rates that are consistent with section 1902(a)(30)(A). The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule, unless otherwise described above. The State provides assurance that it shall reimburse providers directly, except when there are employment or contractual arrangements consistent with section 1902(a)(32). Optional Supporting Material Upload Name Date Created No items available Page 24 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Services MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Service Definitions Provide the state's definitions of the following Health Homes services and the specific activities performed under each service Comprehensive Care Management Definition Comprehensive care management services are: a. Identification of high-risk individuals and use of client information to determine level of participation in care management services; b. assessment of preliminary service needs; treatment plan development, which will include client goals, preferences and optimal clinical outcomes; c. assignment of health team roles and responsibilities; d. development of treatment guidelines that establish clinical pathways for health teams to follow across risk levels or health conditions; e. monitoring of individual and population health status and service use to determine adherence to or variance from treatment guidelines and; f. development and dissemination of reports that indicate progress toward meeting outcomes for client satisfaction, health status, service delivery and costs. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum MO HealthNet maintains a web-based electronic health record (EHR) accessible to enrolled Medicaid providers, including CMHCs, primary care practices and schools. The tool is a HIPAA-client portal that enables providers to: - Download paid claims data submitted for an enrollee by any provider over the past three years (e.g., drug claims, diagnosis codes, CPT codes); - View dates and providers of hospital emergency department services; - Identify clinical issues that affect an enrollee’s care and receive best practice information; - Prospectively examine how specific preferred drug list (PDL) and clinical edit criteria would affect a prescription for an individual enrollee and determine if a prescription meets requirement for Medicaid payment; - Electronically request a drug prior authorization or clinical edit override; pre-certifications for radiology, durable medical equipment (DME), optical and inpatient services; - Identify approved or denied drug prior authorizations or clinical edit overrides or medical pre-certifications previously issued and transmit a prescription electronically to the enrollee’s pharmacy of choice; and - Review laboratory data and clinical trait data; - Determine medication adherence information and calculate medication possession ratios (MPR); and - Offer counseling opportunities for pharmacists through a point of service medication therapy management (MTM) module. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Page 25 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Provider Type Description CMHC Community Mental Health Center Care Coordination Definition Care Coordination is the implementation of the individualized treatment plan (with active client involvement) through appropriate linkages, referrals, coordination and follow-up to needed services and supports, including referral and linkages to long term services and supports. Specific activities include, but are not limited to: appointment scheduling, conducting referrals and follow-up monitoring, participating in hospital discharge processes and communicating with other providers and clients/family members. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum MO HealthNet maintains a web-based electronic health record (EHR) accessible to enrolled Medicaid providers, including CMHCs, primary care practices, and schools. The tool is a HIPAA-client portal that enables providers to: -Download paid claims data submitted for an enrollee by any provider over the past three years (e.g., drug claims, diagnosis codes, CPT codes); -View dates and providers of hospital emergency department services; -Identify clinical issues that affect an enrollee’s care and receive best practice information; -Prospectively examine how specific preferred drug list (PDL) and clinical edit criteria would affect a prescription for an individual enrollee and determine if a prescription meets requirement for Medicaid payment; -Electronically request a drug prior authorization or clinical edit override; pre-certifications for radiology, durable medical equipment (DME), optical and inpatient services; -Identify approved or denied drug prior authorizations or clinical edit overrides or medical pre-certifications previously issued and transmit a prescription electronically to the enrollee’s pharmacy of choice; and -Review laboratory data and clinical trait data; -Determine medication adherence information and calculate medication possession ratios (MPR); and -Offer counseling opportunities for pharmacists through a point of service medication therapy management (MTM) module. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Page 26 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Provider Type Description CMHC Community Mental Health Center Health Promotion Definition Health promotion services shall minimally consist of providing health education specific to an individual’s chronic conditions, development of self-management plans with the individual, education regarding the importance of immunizations and screenings, child physical and emotional development, providing support for improving social networks and providing health- promoting lifestyle interventions, including but not limited to, substance use prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and prevention and increasing physical activity. Health promotion services also assist clients to participate in the implementation of the treatment plan and place a strong emphasis on person-centered empowerment to understand and self-manage chronic health conditions. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum A module of the MO HealthNet comprehensive, web-based EHR allows enrollees to look up their own healthcare utilization and receive the same content in laypersons’ terms. The information facilitates self-management and monitoring necessary for an enrollee to attain the highest levels of health and functioning. Utilization data available through the module includes: -Administrative claims data for the past three years; -Cardiac and diabetic risk calculators; -Chronic health condition information awareness; -A drug information library; and -The functionality to create a personal health plan and discussion lists to use with healthcare providers. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Provider Type Description CMHC Community Mental Health Center Comprehensive Transitional Care from Inpatient to Other Settings (including appropriate follow-up) Definition In conducting comprehensive transitional care, a member of the health team provides care coordination services designed to streamline plans of care, reduce hospital admissions, ease the transition to long term services and supports, and interrupt patterns of frequent hospital emergency department use. The health team member collaborates with physicians, nurses, social workers, discharge planners, pharmacists, and others to continue implementation of the treatment plan with a specific focus on increasing clients’ and family members’ ability to manage care and live safely in the community, and shift the use of reactive care and treatment to proactive health promotion and self management. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Page 27 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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MO HealthNet maintains an initial and concurrent authorization of stay tool which requires hospitals to notify MO HealthNet (via accessing the online authorization tool) within 24 hours of a new admission of any Medicaid enrollee and provide information about diagnosis, condition and treatment for authorization of an inpatient stay. MO HealthNet and the Department of Mental Health are working with the vendor to develop capacity for a daily data transfer listing all new hospital admissions discharges. This information will be transferred to the state’s data analytics contractor which will match it to a list of all persons assigned and/or enrolled in a health home. The contractor would then immediately notify the health home provider of the admission, which would enable the health home provider to: - Use the hospitalization episode to locate and engage persons in need of health home services; - Perform the required continuity of care coordination between inpatient and outpatient; and - Coordinate with the hospital to discharge and avoid readmission as soon as possible. Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Provider Type Description CMHC Community Mental Health Center Individual and Family Support (which includes authorized representatives) Definition Individual and family support services activities include, but are not limited to: advocating for individuals and families, assisting with obtaining and adhering to medications and other prescribed treatments. In addition, health team members are responsible for identifying resources for individuals to support them in attaining their highest level of health and functioning in their families and in the community, including transportation to medically necessary services. A primary focus will be increasing health literacy, ability to self manage their care and facilitate participation in the ongoing revision of their care/treatment plan. For individuals with DD the health home will refer to and coordinate with the approved DD case management entity for services more directly related to Habilitation and coordinate with the approved DD case management entity for services more directly related a particular healthcare condition. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum A module of the MO HealthNet comprehensive, web-based EHR allows enrollees to look up their own healthcare utilization and receive the same content in laypersons’ terms. The information facilitates self-management and monitoring necessary for an enrollee to attain the highest levels of health and functioning. Utilization data available through the module includes: a. Administrative claims data for the past 3 years; b. Cardiac and diabetic risk calculators; c. Chronic health condition information awareness; d. A drug information library; and e. The functionality to create a personal health plan and discussion lists to use with healthcare providers. Scope of service Page 28 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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The service can be provided by the following provider types Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Nutritionists Other (specify) Provider Type Description CMHC Community Mental Health Center Referral to Community and Social Support Services Definition Referral to community and social support services, including long term services and supports, involves providing assistance for clients to obtain and maintain eligibility for healthcare, disability benefits, housing, personal need and legal services, as examples. For individuals with DD, the health home will refer to and coordinate with the approved DD case management entity for this service. Describe how Health Information Technology will be used to link this service in a comprehensive approach across the care continuum Health home providers will monitor continuing Medicaid eligibility using the DFS eligibility website and data base. MO HealthNet and the Department of Mental Health will also develop a process to notify health home providers of impending eligibility lapses (e.g., 60 days in advance). Scope of service The service can be provided by the following provider types Behavioral Health Professionals or Specialists Nurse Practitioner Nurse Care Coordinators Nurses Medical Specialists Physicians Physician's Assistants Pharmacists Social Workers Doctors of Chiropractic Licensed Complementary and alternative Medicine Practitioners Dieticians Page 29 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Nutritionists Other (specify) Provider Type Description CMHC Community Mental Health Center Page 30 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Services MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Health Homes Patient Flow Describe the patient flow through the state's Health Homes system. Submit with the state plan amendment flow-charts of the typical process a Health Homes individual would encounter The CMHC outreach worker or a consumer’s case manager (CsMgr) offers the opportunity to enroll in the health home, and explains that they will be assigned a Nurse Care Manager (NCM) to assist them in improving their health and wellness goals, these services are free, participation is optional, and choosing not to enroll will have NO impact on their currents services. Once an individual enrolls, the CMHC completes a comprehensive health screen. The NCM meets with them to review the results of the screen and their treatment history, and to discuss their wellness, health, and healthcare goals. A multi-disciplinary team collaborates with them to develop a treatment plan, updates at least quarterly, that includes wellness, health, healthcare, and self-management goals. The consumer’s Primary Care Physician (PCP) is notified of enrollment in the health home. If they don’t have a PCP, the CMHC works to connect them with one. The team members carry out their assigned plan responsibilities related to wellness, health status, chronic disease management, housing, employment, and care coordination. NCMs update care management registries for each individual on their caseload monthly. The registries enable NCMs to identify if consumers receive psychotropic medications outside of best practice guidelines; if they fail to fill prescribed medications for chronic health conditions or psychotropic medications; if consumers with hypertension, diabetes, and cardiovascular disease have lab values that exceed desired levels; and to track progress in controlling BMI levels, tobacco use, and metabolic screening values. CsMgrs accompany consumers to visits with their PCPs and assist them to improve their health status and manage chronic health conditions. If they achieve their goals, they may be discharged, or transferred to a Primary Care Health Home for continued care management with the option of returning to the CMHC if needed. Name Date Created Flow Chart for Individuals Engaged thru Outreach 8/22/2019 3:24 PM EDT Flow Chart for Existing CMHC Consumer 8/22/2019 3:24 PM EDT Page 31 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Monitoring Describe the state's methodology for calculating cost saving (and report cost savings annually in Quality Measure Report). Include savings that result from improved coordination of care and chronic disease management achieved through the Health Homes Program, including data sources and measurement specifications, as well as any savings associated with dual eligibles, and if Medicare data was available to the state to utilize in arriving at its cost-savings estimates The State will annually perform an assessment of cost savings using a pre/post-period comparison. The assessment will include total Medicaid savings for the intervention group and will be subdivided by category of service. It will also be broken out for each CMHC Health Home. The data source will be Medicaid claims and the measure will be PMPM Medicaid expenditure. Savings calculations will be trended for inflation and will truncate the claims of high-cost outliers annually exceeding three standard deviations of the mean. Savings calculations will include the cost of PMPM payments received by Health Home Providers. The assessment will also include the performance measures enumerated in the Quality Measures section. Describe how the state will use health information technology in providing Health Homes services and to improve service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider) To facilitate the exchange of health information in support of care for patients receiving or in need of health home services, the state will utilize several methods of health information technology (HIT). The following is a summary of HIT currently available for Health Home providers to conduct comprehensive care management, care coordination, health promotion, individual and family support and referral to community and social support services. Also included is a description of the state’s process to improve health information exchange (HIE) for comprehensive transitional care services. As Missouri implements its Health Home models, the State will also be working toward the development of a single data portal to facilitate information exchange, measures documentation and calculation and state reporting to CMS. The state will also continue to refine a process for HIE between CMHCs and primary care practices and has contacted SAMSHA to learn more about opportunities available under the national technical assistance center on integrated care. 1. HIT for Comprehensive Care Management and Care Coordination – MO HealthNet maintains a web-based electronic health record (EHR) accessible to enrolled Medicaid providers, including CMHCs, primary care practices, and schools. The tool is a HIPAA-compliant portal that enables providers to: (a) Download paid claims data submitted for an enrollee by any provider over the past three years (e.g., drug claims, diagnosis codes, CPT codes);; (b) View dates and providers of hospital emergency department services; (c) Identify clinical issues that affect an enrollee’s care and receive best practice information; d) Prospectively examine how specific preferred drug list (PDL) and clinical edit criteria would affect a prescription for an individual enrollee and determine if a prescription meets requirement for Medicaid payment; e) Electronically request a drug prior authorization or clinical edit override; pre-certifications for radiology, durable medical equipment (DME), optical and inpatient services; (f) Identify approved or denied drug prior authorizations or clinical edit overrides or medical pre-certifications previously issues and transmit a prescription electronically to the enrollee’s pharmacy of choice; and (g) Review laboratory data and clinical trait data; (h) Determine medication adherence information and calculate medication possession ratios (MPR); and (i)Offer counseling opportunities for pharmacists through a point of service medication therapy management (MTM) module. 2. HIT for Health Promotion and Individual and Family Support Services – A module of the MO HealthNet comprehensive, web based EHR allows enrollees to access their own healthcare utilization information and receive the same content in laypersons’ terms. The information facilitates self-management and monitoring necessary for an enrollee to attain the highest levels of health and functioning. Health Home providers will provide instruction to individuals on the use of the module. Utilization data available through the module includes: (a) Administrative claims data for the past 3 years; (b) Cardiac and diabetic risk calculators; (c) Chronic health condition information awareness (d) A drug information library; and (e) The functionality to create a personal health plan and discussion lists to use with healthcare providers. 3. HIT for Comprehensive Transitional Care – MO HealthNet maintains an initial and concurrent authorization of stay tool which requires Page 32 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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hospitals to notify MO HealthNet (via accessing the online authorization tool) within 24 hours of the next usual workday regarding a new admission of any Medicaid enrollee and provide information about diagnosis, condition and treatment for authorization of an inpatient stay. MO HealthNet and the Department of Mental Health are working with the vendor to develop capacity for a daily data transfer listing all new hospital admissions discharges. This information will be transferred to the states data analytics contractor which will match it to a list of all persons assigned and/or enrolled in a Health Home. The contractor would then immediately notify the Health Home provider of the admission, which would enable the Health Home provider to: (a) Use the hospitalization episode to locate and engage persons need of health home services; (b) Perform the required continuity of care coordination between inpatient and outpatient; and (c) Coordinate with the hospital to discharge an avoidable admission as soon as possible. The daily data transfer will be in place within six months of implementation of the SPA. In the interim, Health Homes will continue to implement or develop memoranda of understanding (MOU) with local hospitals for notification about hospital admissions. 4. Referral to Community and Social Support Services – Health Home providers will be encouraged to monitor continuing Medicaid eligibility using the FSD eligibility website and data base. MO HealthNet and the Department of Mental Health will also refine process to notify Health Home providers of impending eligibility lapses (e.g., 60 days in advance). 5. Specific HIT Strategies for CMHCs Customer Information Management, Outcomes and Reporting (CIMOR) - CMHCs will continue to utilize CIMOR for routine functions (e.g., contract management, billing, benefit eligibility, etc.); however CIMOR’s capacity will continue to be expanded in support of CMHC comprehensive care management and care coordination functions. CIMOR will enable assignment of enrollees to a CMHC Health Home based on enrollee choice and admission for services. CMHC Health Home providers utilize CIMOR to report Department of Mental Health required outcome measures. In addition, the CMHC Health Home enrollment data in CIMOR will be cross referenced with MO Health Net inpatient pre-authorization data to enable the automated real-time reporting of inpatient authorizations to the appropriate CMHC. 6. Behavioral Pharmacy Management System (BPMS) – CMHCs utilize BPMS to receive aggregate and individual identification and reporting of potentially problematic prescribing patterns. Page 33 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Monitoring, Quality Measurement and Evaluation MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0003O | MO-19-0017 | Migrated_HH.Community Mental Health Center – Health Homes Package Header Package ID MO2019MS0003O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID 16-0007 User-Entered SPA ID MO-19-0017 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Quality Measurement and Evaluation The state provides assurance that all Health Homes providers report to the state on all applicable quality measures as a condition of receiving payment from the state The state provides assurance that it will identify measureable goals for its Health Homes model and intervention and also identify quality measures related to each goal to measure its success in achieving the goals The state provides assurance that it will report to CMS information submitted by Health Homes providers to inform evaluations, as well as Reports to Congress as described in Section 2703(b) of the Affordable Care Act and as described by CMS The state provides assurance that it will track avoidable hospital readmissions and report annually in the Quality Measures report Page 34 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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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 0938-1188. The time required to complete this information collection is estimated to average 40 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. This view was generated on 11/13/2019 3:54 PM EST Page 35 of 35 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
(spa)(mo-19-0020)(approval-document)Missouri Medicaid SPA MO-19-0020: Approval Document (approved November 13, 2019, effective July 1, 2019)#
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Table of Contents State/Territory Name: MO State Plan Amendment (SPA) #: 19-0020 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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Records / Submission Packages MO - Submission Package - MO2019MS0004O - (MO-19-0020) - Health Homes CMS-10434 OMB 0938-1188 Package Information Package ID MO2019MS0004O Program Name Missouri-2 Health Home Services SPA ID MO-19-0020 Version Number 5 Submitted By Marissa Crump Package Disposition Priority Code P2 Submission Type Official State MO Region Kansas City, KS Package Status Approved Submission Date 9/26/2019 Approval Date 11/13/2019 3:20 PM EST Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions Page 1 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Kansas City Regional Office 601 E. 12th Street, Suite 355 Kansas City, MO 64106 Division of Medicaid and Children's Health Operations November 13, 2019 Todd Richardson Director MO HealthNet Division 615 Howerton Court Jefferson City, MO 65109 Re: Approval of State Plan Amendment MO-19-0020 Missouri-2 Health Home Services Dear Todd Richardson: On September 26, 2019, the Centers for Medicare and Medicaid Services (CMS) received Missouri State Plan Amendment (SPA) MO-19-0020 for Missouri-2 Health Home Services to add a 1.5% rate increase to the per-member-per-month payment rate for Primary Care Health Homes. We approve Missouri State Plan Amendment (SPA) MO-19-0020 on November 13, 2019 with an effective date(s) of July 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact Karen Hatcher at karen.hatcher@cms.hhs.gov. Sincerely, James G. Scott Division of Medicaid Field Operations - North Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date N/A State Information State/Territory Name: Missouri Medicaid Agency Name: MO HealthNet Division Submission Component State Plan Amendment Medicaid CHIP Page 2 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date N/A SPA ID and Effective Date SPA ID MO-19-0020 Reviewable Unit Proposed Effective Date Superseded SPA ID Health Homes Payment Methodologies 7/1/2019 MO-19-0003 Page 3 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives SPA 19-0020 adds a 1.5% rate increase to the per-member-per-month payment rate for Primary Care Health Homes effective July 1, 2019. This health home SPA (19-0003) was transitioned from MMDL to MACPro with the September 1, 2019, effective date. The payment methodology had no changes during the SPA transition. After SPA 19-0003 was submitted, the state mandated a 1.5 rate increase effective July 1, 2019. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $20216 Second 2020 $243513 Federal Statute / Regulation Citation Section 2703 of the Affordable Care Act and Section 1945 of the Social Security Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Page 4 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Summary MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Page 5 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Public Notice/Process MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date N/A Name of Health Homes Program Missouri-2 Health Home Services Public notice was provided due to proposed changes in methods and standards for setting payment rates for services, pursuant to 42 CFR 447.205. Upload copies of public notices and other documents used Name Date Created PublicNoticeFY20RateIncrease 11/7/2019 3:26 PM EST Page 6 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Tribal Input MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date N/A Name of Health Homes Program: Missouri-2 Health Home Services One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No Page 7 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Submission - Other Comment MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID N/A SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date N/A SAMHSA Consultation Name of Health Homes Program Missouri-2 Health Home Services The State provides assurance that it has consulted and coordinated with the Substance Abuse and Mental Health Services Administration (SAMHSA) in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions. Date of consultation 6/30/2016 Page 8 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID MO-19-0003 System-Derived SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Payment Methodology The State's Health Homes payment methodology will contain the following features Fee for Service Individual Rates Per Service Per Member, Per Month Rates Fee for Service Rates based on Severity of each individual's chronic conditions Capabilities of the team of health care professionals, designated provider, or health team Other Describe below See description in Rate Development section below. Comprehensive Methodology Included in the Plan Incentive Payment Reimbursement Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Health Home services. The agency’s per-member-per-month (PMPM) rate was set as of July 1, 2019, and is effective for services provided on or after that date. PCCM (description included in Service Delivery section) Risk Based Managed Care (description included in Service Delivery section) Alternative models of payment, other than Fee for Service or PMPM payments (describe below) Page 9 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID MO-19-0003 System-Derived SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Agency Rates Describe the rates used FFS Rates included in plan Comprehensive methodology included in plan The agency rates are set as of the following date and are effective for services provided on or after that date Effective Date 7/1/2019 Website where rates are displayed https://dss.mo.gov/mhd/cs/health-homes/pdf/pchh-per-member-per- month-rates.pdf Page 10 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID MO-19-0003 System-Derived SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Rate Development Provide a comprehensive description in the SPA of the manner in which rates were set 1. In the SPA please provide the cost data and assumptions that were used to develop each of the rates 2. Please identify the reimbursable unit(s) of service 3. Please describe the minimum level of activities that the state agency requires for providers to receive payment per the defined unit 4. Please describe the state's standards and process required for service documentation, and 5. Please describe in the SPA the procedures for reviewing and rebasing the rates, including • the frequency with which the state will review the rates, and • the factors that will be reviewed by the state in order to understand if the rates are economic and efficient and sufficient to ensure quality services. Comprehensive Description Cost Assumptions/Factors Used to Determine Payment: Missouri will pay PCHH the cost of staff primarily responsible for delivery of services not covered by other reimbursement (Nurse Care Managers, Behavioral Health Consultants, Care Coordinators and Health Home Directors) whose duties are not otherwise reimbursable by MO HealthNet. In addition, PCHH Health Homes receive payments related to Health Home specific training, technical assistance, administration, and data analytics. All payments are contingent on the Health Home meeting the requirements set forth in their Health Home applications, as determined by the State of Missouri. Failure to meet such requirements is grounds for revocation of Health Home status and termination of payments. Clinical Care Management per-member-per-month (PMPM) payment: • Staff cost is based on a provider survey of all PCHH statewide and includes fringe, operating & indirect costs. • All PCHH providers will receive the same PMPM rate. • The PMPM method will be reviewed periodically to determine if the rate is economically efficient and consistent with quality of care. Minimum Criteria for Payment The criteria required for receiving the PMPM rate payment is: A. The person is identified as meeting PCHH eligibility criteria on the State-run health home patient registry; B. The person is enrolled as a health home member at the billing health home provider; C. The minimum health home service required to merit payment of the PMPM is that the person has received Care Management monitoring for treatment gaps; or another health home service was provided that was documented by a health home director and/or nurse care manager; and D. The health home will report that the minimal service required for the PMPM payment occurred on a monthly health home activity report. Page 11 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MO2019MS0004O | MO-19-0020 | Missouri-2 Health Home Services Package Header Package ID MO2019MS0004O Submission Type Official Approval Date 11/13/2019 Superseded SPA ID MO-19-0003 System-Derived SPA ID MO-19-0020 Initial Submission Date 9/26/2019 Effective Date 7/1/2019 Assurances The State provides assurance that it will ensure non-duplication of payment for services similar to Health Homes services that are offered/covered under a different statutory authority, such as 1915(c) waivers or targeted case management. Describe below how non- duplication of payment will be achieved Managed Care: All Health Home payments including those for MO HealthNet (MHN) participants enrolled in managed care plans will be made directly from MHN to the Health Home provider. As a result of the additional value that managed care plans will receive from MHN direct paid Health Home services, the managed care plan is not required to provide care coordination or case management services that would duplicate the CMS reimbursed health home services (i.e. the conditions for which an individual was enrolled in the Health Home). This Health Home delivery design and payment methodology will not result in any duplication of payment between Health Homes and managed care. The managed care plan will be informed of its members that are in Health Home services and a managed care plan contact person will be provided for each Health Home provider to allow for coordination of care. • The managed care plan will be required to inform either the individual’s Health Home or MHN of any inpatient admission or discharge of a Health Home member that the plan learns of through its inpatient admission initial authorization and concurrent review processes within 24 hours. • The PCHH team will provide Health Home services in collaboration with MCO network primary care physicians in the same manner as they will collaborate with any other primary care physician who is serving as the PCP of an individual enrolled in the PCHH. The state has developed payment methodologies and rates that are consistent with section 1902(a)(30)(A). The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule, unless otherwise described above. The State provides assurance that it shall reimburse providers directly, except when there are employment or contractual arrangements consistent with section 1902(a)(32). Optional Supporting Material Upload Name Date Created No items available Page 12 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
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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 0938-1188. The time required to complete this information collection is estimated to average 40 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. This view was generated on 11/13/2019 3:48 PM EST Page 13 of 13 Medicaid State Plan Print View 11/13/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...
(spa)(mo-19-0021)(approval-document)Missouri Medicaid SPA MO-19-0021: Approval Document (approved February 26, 2020, effective October 1, 2019)#
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Table Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #: 20-0018 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Lori Shibinette, Commissioner Department of Health and Human Services State of New Hampshire 129 Pleasant Street Concord, NH 03301 RE: TN 20-0018 Dear Commissioner Shibinette: We have reviewed the proposed New Hampshire (NH) State Plan Amendment (SPA) to Attachment 4.19-B, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 20, 2020. This plan amendment updates the allowance for a 3.1% increase to Federally Qualified Health Center (FHQC) and Rural Health Clinic (RHC) rates. Based upon the information provided by the State, we have approved the amendment with an effective date of January 01, 2020. We are enclosing the approved CMS-179 and a copy of the new state plan pages. Please note that our approval relates only to the requested change in payment methodology and CMS may still have questions on the funding structure in determining its consistent with section 1902(a)(2) and 1903(a) of the Act as implemented by 42 CFR § 433.54. Therefore, our approval relates only to the requested change in payment methodology and that the resultant rates and related expenditures are consistent with section 1902(a)(30)(A) of the Act. Approval of the subject SPA does not relieve the State of its responsibility to comply with federal laws and regulations, and to ensure that claims for federal funding are consistent with all applicable requirements. If you have any additional questions or need further assistance, please contact James Moreth at 206-615-2043 or James.Moreth@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures cc: Henry Lipman, State Medicaid Director Diane Peterson, Medicaid Business and Policy April 17, 2020
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DEPARTMENT OF HEALTH ANDHUMAN SERVICES. FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0996-0193
7. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF 20-0018 _ NH STATE PLAN MATERIAL —— —_———__— FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES January 1, 2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5, TYPE OF PLAN MATERIAL (Check One) | DINEW STATE PLAN (AMENDMENT TO BE CONSIDERED AS NEW PLAN BIAMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6, FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT 42 CFR 440.20, 42 CFR Part 447, BIPA 2000, 1902(bb)(6) FFY 2020: $22,577 FFY 2021: $30,103 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable) Attachment 4.19-B, Page 5a and 5g Attachment 4.19-B, Page 5a (TN 12-009) Attachment 4.19-B, Page 5g {TN 12-009)
10. SUBJECT OF AMENDMENT
Federally Qualified Health Centers/Rural Health Clinics-Non-Hospital Based/Rural Health Clinics-Hospital Based - NH 2020 Budget Increase
11. GOVERNOR'S REVIEW (Check One)
+ » DIGOVERNOR'S OFFICE REPORTED NO COMMENT BAOTHER, AS SPECIFIED: comments, if any, will follow
COCOMMENTS OF GOVERNOR'S OFFICE ENCLOSED ~~ [JNO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
12. SIGNA’ 16. RETURN TO
Dawn Landry
Division of Medicaid Services/Brown Building Department of Health and Human Services 14. TITLE Associate Commissioner Concord: wi Siroet
413. TYPEO NAME) =—s Ann H. Landry
15. DATE SUBMITTED Al zo] We2o
FOR REGIONAL OFFICE USE ONLY
17. DATE RECEIVED 03/20/2020 16. DATE) APEROVED
PLAN APPROVED - ONE COPY ATTACHED
CEE EO TS rr 19. EFFECTIVE DATE OF APPROVED MATERIAL re 01/01/2020
21. TYPED NAME 22. TITLE
Todd McMillion Director, Division of Reimbursement Review 23. REMARKS
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Title XIX – NH Attachment 4.19-B Page 5a PAYMENT RATES FOR ALL TYPES OF CARE OTHER THAN INPATIENT HOSPITAL, SKILLED NURSING, OR INTERMEDIATE NURSING CARE SERVICES **Addendum to 21 and 23 above, RHC’s, FQHC’s and FQHC-LAL’s (continued): Description of Alternative Payment Methodology – RHC’s, FQHC’s and FQHC-LAL’s (21 and 23 above) 21a and 23. Rural Health Clinics - Non-Hospital Based (RHC-NHB), Federally Qualified Health Centers (FQHC’s) and FQHC Look-A-Likes (LAL’s) a) General Payment for RHC-NHB’s, FQHC’s, and FQHC-LAL’s conforms to Section 702 of the Benefits Improvement and Protection Act (BIPA) of 2000. The NH Department of Health and Human Services (the Department) determines an encounter rate for primary, preventive care services using an Alternative Payment Methodology (APM) under SSA 1902(bb)(6). The encounter rate is an all-inclusive rate of payment for primary, preventive care covered services defined in 1905(a)(2)(B) and (C) of the Social Security Act and included in the NH Title XIX State Plan to eligible Medicaid recipients. The Alternative Payment Methodology (APM) is calculated using the providers’ fiscal year 2011 cost-settled rates as the baseline for all subsequent years’ encounter rates trending forward using the Medicare Economic Index (MEI) published annually for each of those years. The cost settlement process applied to the 2011 baseline limited each provider to the lesser of their actual costs or 133% of the Medicare rate. The Department also calculates an encounter rate using a Prospective Payment Methodology (PPS) and the formula established by BIPA 2000, using the average cost based rate per visit for provider fiscal years of 1999 and 2000, trended forward by the MEI. The baseline rates for RHC-NHB’s, FQHC’s, and FQHC-LAL’s that did not have any reported costs in either the APM or PPS baseline will be set as an average of the rates for similar clinics or centers in the same urban or rural settings. The effective date for such rates is the effective Medicaid enrollment date for the provider. Effective October 8, 2012, each provider will receive an encounter rate that is the greater of the APM or PPS. Only those providers that agree in writing to the proposed APM will receive the proposed APM. Thereafter, annually on July 1, each provider’s encounter rate will be trended forward by the MEI and adjusted for any approved change in scope of services (see below). Effective January 1, 2020, the encounter rate will be increased 3.1%. TN No: 20-0018 Supersedes Approval Date ________ Effective Date: 01/01/2020 TN No: 12-009 04/17/20
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Title XIX – NH Attachment 4.19-B Page 5g PAYMENT RATES FOR ALL TYPES OF CARE OTHER THAN INPATIENT HOSPITAL, SKILLED NURSING, OR INTERMEDIATE NURSING CARE SERVICES **Addendum to 21 and 23 above RHC’s, FQHC’s and FQHC-LAL’s (continued): Description of Alternative Payment Methodology – RHC’s, FQHC’s and FQHC-LAL’s (21 and 23 above) 21b. Rural Health Clinics (RHC’s) – Hospital Based Hospital-based RHC’s are reimbursed a percent of costs. Each hospital, after the close of its own unique fiscal period, submits the Medicare Cost Report (CMS Form 2552) as required by Medicare, which is subsequently audited by the Medicare Fiscal Intermediary according to the Medicare auditing schedule and principles of reimbursement. Allowable costs are allocated to the hospital-based RHC services rendered to NH Medicaid recipients on Worksheet M-3. Effective for services on and after January 1, 2020, the current reimbursable amount of the costs is 94.10%. The reimbursable costs based on the audit are then compared to interim payments that were made during the unique cost period for that hospital, and the difference is the settlement that is payable to the hospital-based RHC or to the Department. Based on the settlement, the interim rate is also established for the hospital’s next cost period by taking a Ratio of Cost to Charges (RCC) derived from the last settlement processed. This is an ongoing process that occurs as hospitals submit cost reports when their unique fiscal years end. Laboratory services provided as part of a hospital based RHC encounter are reimbursed through an add-on fee which is paid in addition to the percentage of cost payment for the encounter. The add-on fee is the same laboratory fee-for-service fee schedule used for all laboratory services reimbursement effective as noted in the NH Title XIX State Plan, Attachment 4.19-B, page 1-1, and is the same fee schedule used for both governmental and private providers. The fee schedule can be found at www.nhmmis.nh.gov (see “documents and forms” under the documentation tab). Vaccine administration is paid as part of the encounter. However, if vaccine is not administered as part of or incidental to an encounter, the vaccine administration can be billed separately and will be reimbursed at the interim rate and cost settled as per above. The actual vaccine is reimbursed for adults age 19 and older regardless of whether the administration of such vaccine is part of the encounter or billed separately and is billed with a pharmacy revenue code and paid an interim rate which is subsequently cost settled as per above. TN No: 20-0018 Supersedes Approval Date ________ Effective Date: 01/01/2020 TN No: 12-009 04/17/20
(spa)(mo-19-0024)(approval-document)Missouri Medicaid SPA MO-19-0024: Approval Document (approved January 6, 2020, effective January 1, 2020)#
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Table of Contents State/Territory Name: MO State Plan Amendment (SPA) #: 19-0024 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106-2898
Medicaid & CHIP Operations Group
January 10, 2020
Jennifer Tidball, Acting Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, MO 65102-1527
Dear Ms. Tidball:
On December 5, 2019, the Centers for Medicare & Medicaid Services (CMS) received Missouri’s State Plan Amendment (SPA) transmittal #19-0024. This SPA adds language to allow chiropractic physicians to become MO HealthNet (MHD) providers.
SPA #19-0024 was approved January 6, 2020, with an effective date of January 1, 2020, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Missouri State Plan.
If you have any questions regarding this amendment, please contact Karen Hatcher or Deborah Read at (816) 426-5925.
1/10/2020 X Signed by: James G. Scott -S
Enclosure
cc:
Todd Richardson Nanci Nikodym Marissa Crump
James G. Scott, Director Division of Program Operations Sincerely,
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December 5, 2019 January 6, 2020 January 1, 2020 James G. Scott Director, Division of Program Operations
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Attachment 3.1 A Revised Submission 12.12.19 Page 12aa State Plan TN# 19 0024_ Effective Date: January 1,2020 Superseded TN# 19 0018 Approval Date State: Missouri 6.d. Other Practitioner’s Services Physician Assistant Physician Assistant services are covered within their scope of practice defined by state law. Physicians Assistants are supervised by licensed physicians, and supervision of the Physician Assistant is included in the scope of practice for each supervising licensed practitioner. Each supervising licensed practitioner shall assume professional responsibility for the services provided by the Physician Assistant. Assistant Physician Assistant Physician services are covered within their scope of practice defined by state law. Assistant Physicians are supervised by licensed physicians, and supervision of the Assistant Physician is included in the scope of practice for each supervising licensed practitioner. Each supervising licensed practitioner shall assume professional responsibility for the services provided by the Assistant Physician. Emergency Medical Technicians Licensed emergency medical technicians (EMT) are covered within their scope of practice defined by state law. Paramedics Licensed paramedics are covered within their scope of practice defined by state law. Chiropractor Chiropractic services are limited to twenty visits per year for services limited to examinations, diagnoses, adjustments, and manipulations and treatments of malpositioned articulations and structures of the body provided by licensed chiropractors practicing within their scope of practice define by state law. Additional services will be provided if medically necessary. January 6, 2020
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Attachment 4.19 B Page 9aa State: Missouri PHYSICIAN ASSISTANT SERVICES Except as otherwise noted in the plan, state developed fee schedule rates are the same for both public and private providers of physician assistant services. The agency’s fee schedule rate was set as of July 14, 2014, and is effective for services provided on or after July 14, 2014. All rates are published at https:// dss.mo.gov/mhd/providers/ pages/cptagree.htm. ASSISTANT PHYSICIAN SERVICES Except as otherwise noted in the plan, state developed fee schedule rates are the same for both public and private providers of assistant physician services. The agency’s fee schedule rate was set as of January 7, 2019, and is effective for services provided on or after that date. All rates are published at https:// dss.mo.gov/mhd/providers/ pages/ cptagree.htm. CHIROPRACTIC SERVICES Except as otherwise noted in the plan, state developed fee schedule rates are the same for both public and private providers of chiropractic services. The agency’s fee schedule rate was set as of January 1, 2019, and is effective for services provided on or after that date. All rates are published at https:// dss.mo.gov/mhd/providers/ pages/ cptagree.htm. Effective Date January 1, 2020 State Plan TN# 19 0024 Supersedes TN# 18 0023 Approval Date __________ January 6, 2020
(spa)(mo-20-0007)(approval-document)Missouri Medicaid SPA MO-20-0007: Approval Document (approved June 25, 2020, effective April 1, 2020)#
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Table of Contents State/Territory Name: Missouri State Plan Amendment (SPA) #: 20-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106-2898
Medicaid and CHIP Operations Group
July 01, 2020
Jennifer Tidball, Acting Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, MO 65102-1527
Re: Missouri State Plan Amendment (SPA) 20-0007
Dear Ms. Tidball:
On May 7, 2020, the Centers for Medicare & Medicaid Services (CMS) received Missouri State Plan (SPA) No. 20-0007. This SPA was submitted to request a waiver of the regulatory requirement at 42 CFR 455, Subpart F to enter into a contract with a Medicaid Recovery Audit Contractor (RAC) vendor to identify overpayments and underpayments and to recoup overpayments.
We are pleased to inform you that SPA 20-0007 was approved on June 25, 2020, with an effective date of April 1, 2020, as requested by the State, through March 31, 2022. At this time, it is not permissible to grant an exception to this policy indefinitely or for more than two years. Enclosed is a copy of the CMS 179 summary form, as well as the approved pages for incorporation into the Missouri State Plan.
If you have any questions regarding this matter you may contact Deborah Read (816) 426-5925 or by e-mail at Deborah.read@cms.hhs.gov.
X
Enclosures
cc: Todd Richardson, SMD, MHD
Glenda Kremer, MHD
Megan Buck, Program Branch Manager Marissa Crump, MHD Ruth A. Hughes, Acting Director Division of Program Operations Sincerely,
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DEPARTMENT OF HEALTH ANO HUMAN SERVICES CENTERS FOR MEDICARE.& MEDICAIO SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER 2 0 -00 07 -- -- 2. STATE MO !'ORM APPROVED 0'-18 No. 0030·0\IIJ FOR: CENTERS FOl'I MEDICARE & MEDICAID SERVICES 3. PROGRAM IOENTIACATION: Tlll.E XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONALADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH ANO HUMAN SERVJCES 5. TYPE OF PLAN MATERIAL (Check One) April 1, 2020 0 NEW STATE PLAN O AMENDMENT TO BE: CONSIDERED AS NEW PLAN ʂ AMENDMENT COMPLETE BLOCKS 6 THAU 10 JF THIS IS AN AMENDMENT (Separa/e transmi«al for each amendment} 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT 42CFR455.516
=I :-',:------ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION 36b, 36bb OR ATTACHMENT (II Applir;ab/ʃ) 36b, 36bb 10. SUBJECT OF AMENDMENT Waiver of State's requirement to contract with a_ Recovery Audit Contractor (RAC) t1. OVERN R'S REVIEW (Choci< One) -sY GOVERNOR'S OFFICE REPORlED NO COMMENT COMMENTS Of GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNAT. FJ!, o 13. TYE ·, ,;AJ.,,AJI , 14.TITLE-Pcr; j,C J)', re C;:;br 15. DATE SUBMITTEDu (j,S--07 - □OTHER, AS SPECIFIED 16. RETURN TO MO HealthNet Division P.O. Box 6500 Jefferson City, MO 65102 FOR REGlONAL OFFICE USE ONLY 17. DATE RECEIVED 118. DATE APPROVED •. PLAN APPROVED -ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICI L 21. TYPED NAME 22. TITLE 23. REMARKS FORM CMS--179 (071921 Instructions on Sack 05/07/2020 06/25/2020 04/01/2020 Ruth A. Hughes Acting Director, Division of Program Operations
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36b TN No. _20-0007____________ Approval Date: _____________________ Supersedes TN No. 18-006_____ Effective Date: _April 1, 2020________ State: Missouri PROPOSED SECTION 4 – GENERAL PROGRAM ADMINISTRATION 4.5 Medicaid Recovery Audit Contractor Program Citation Section 1902(a)(42)(B)(i) of the Social Security Act Section 1902(a)(42)(B)(ii)(I) of the Act Section 1902 (a)(42)(B)(ii)(II)(aa) of the Act The State has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State plan and under any waiver of the State plan. __X__ The State is seeking an exception to establishing such program until April 1, 2022 for the following reasons: The request for proposal for a recovery audit contractor to begin work December 1, 2015 was issued June 30, 2015 – RFP B3Z15262. The response period closed July 30, 2015. Missouri received no responses. A second request for proposal for a recovery audit contractor to begin work on December 1, 2015 was issued August 13, 2015 – RFP B3Z16035. The response period closed September 14, 2015. Missouri received no responses. Missouri’s previous contractor was Cognosante, LLC. The Cognosante project manager advised our office that Cognosante did not intend to bid during the response period because the RAC area of business was not cost-beneficial for their company. Missouri did not receive feedback from other vendors regarding their decisions not to place a bid but for the following reasons Missouri has chosen not request any additional proposals. This SPA will be in effect for two (2) years, and as long as Missouri maintains a program to recover credit balances on patient accounts and maintains a strong and effective program to recover improperly paid monies through Program Integrity efforts. Factors supporting Missouri’s exception: 1. Missouri holds a contract with HMS, in part to provide Credit Balance Audits, a function previously provided under the Cognosante contract. HMS continues to recover more in credit balance audit recoveries than Cognosante previously recovered in its most recent year. 2. Missouri has strong and effective controls to minimize the risk of improper payments, including recoveries from provider audits, special projects, investigations, and cost avoidance measures. Missouri works closely with the Medicaid Fraud Control Unit referring many cases for prosecution in each State Fiscal Year. June 25, 2020
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36bb TN No. __20-0007____________ Approval Date: ____________ Supersedes TN No. 18-006_____ Effective Date: April 1, 2020 3. The final rule at § 455.506(a)(1) indicates, “States may exclude Medicaid managed care claims from review by Medicaid RAC,” Managed care claims comprise approximately 18% of the Missouri Medicaid payments for health care as Missouri’s managed care penetration is 80%. _ _The State/Medicaid agency has contracts of the type(s) listed in section 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute. Place a check mark to provide assurance of the following: The State will make payments to the RAC(s) only from amounts recovered. The State will make payments to the RAC(s) on a contingent Basis for collecting overpayments. The following payment methodology shall be used to determine State payments to Medicaid RACs for identification and recovery of overpayments (e.g., the percentage of the contingency fee): The State attests that the contingency fee rate paid to the Medicaid RAC will not exceed the highest rate paid to Medicare RACs, as published in the Federal Register. June 25, 2020
(spa)(mo-20-0012)(approval-document)Missouri Medicaid SPA MO-20-0012: Approval Document (approved June 17, 2020, effective March 1, 2020)#
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Table of Contents State/Territory Name: Missouri State Plan Amendment (SPA) #: 20-0012 This file contains the following documents in the order listed:
1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 June 1, 2020 Jennifer Tidball Acting Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, Missouri 65102 Re: Missouri State Plan Amendment (SPA) 20-0012 Dear Ms. Tidball: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0012. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID-
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19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of Missouri also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C), CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. These waivers or modifications of the requirements related to SPA submission timelines DQG public notice apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Missouri’s Medicaid SPA Transmittal Number 20-0012 is approved effective March 1, 2020. This SPA is in addition to Missouri’s Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Deborah Read at 816-426-6363 or by email at Deborah.Read@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Missouri and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.06.17 08 02:17 -04'00'
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB No 0938-0:93
TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES
1, TRANSMITTAL NUMBER 2. STATE 2a _|Missouri
3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)
—o 9
12
TO: REGIONAL ADMINISTRATOR CENTERS FOA MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES
4. PROPOSED EFFECTIVE DATE
March 1, 2020
§. TYPE OF PLAN MATERIAL (Check One) [NEW STATE PLAN
Cy AMENDMENT TO BE CONSIDERED AS NEW PLAN
] AMENDMENT
COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmiltial tor each amendment)
6, FEDERAL STATUTE/REGULATION CITATION
Section 1135 of the Social Security Act; Title XIX of the Social Security Act
7, FEDERAL BUDGET IMPACT a, FFY20 id b. FFY21 $ 2°
8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT
Section 7.4 Medicaid Disaster Relief For COVID-19 National Emergency - New Pages 99-109 *
9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable)
New
10. SUBJECT OF AMENDMENT
The purpose of this amendment is to make state plan changes needed due to COVID-19,
1
11. GAYERNOR’S REVIEW (Check One) Vv
OVERNOR'S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (J NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
(1 OTHER, AS SPECIFIED
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15. DATE SUBMITTED OS-07- 2330
16. RETURN TO MO HealthNet Division P.O. Box 6500
Jefferson City, MO 65102
FOR REGIONAL OFFICE USE ONLY
17. DATE RECEIVED May 7, 2020
18. DATE APPROVED June 17, 2020
PLAN APPROVED - ONE COPY ATTACHED
19, EFFECTIVE DATE OF APPROVED MATERIAL March.1, 2020
20. SIGNATURE OF REGIONAL OFFICIAL
Digitally signed by Anne M. Costello Anne M. Costello -S Sake 2000.00.17 08.0243 4
21. TYPED NAME
Anne Marie Costello
22. TITLE Deputy Director, CMCS
23. REMARKS
* Pen and Ink change per states request dated 5.22.20
FORM CMS-179 (07/92)
instructions on Back
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVIDͲ19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVIDͲ19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVIDͲ19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVIDͲ19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVIDͲ19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 ___X__ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. ___X__ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X___ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. c. _____ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of state] Medicaid state plan, as described below: Please describe the modifications to the timeline. Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ ͲorͲ b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies: 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. Less restrictive resource methodologies: 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are nonͲresidents: 6. _____ The agency provides for an extension of the reasonable opportunity period for nonͲ citizens declaring to be in a satisfactory immigration status, if the nonͲcitizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90Ͳday reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods. 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGIͲ based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in callͲcenters or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Missouri Medicaid suspends Medicaid copayments for all items and services for all eligibility groups. The cost sharing policy approved in 20Ͳ0012 supersedes the cost sharing policy approved in 20Ͳ0013. 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: :ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. b. _____ The following eligibility groups or categorical populations: Please list the applicable eligibility groups or populations. 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. __X__ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): Other Practitioner Services Allow licensed pharmacists practicing within their scope of practice to: order, collect specimens, conduct tests, interpret tests, and administer vaccines for the diagnosis, treatment, and prevention of COVIDͲ19. Allow licensed pharmacists practicing within their scope of practice to administer any prescribed injectable covered outpatient drug during the COVIDͲ19 pandemic. 2. __X___ The agency makes the following adjustments to benefits currently covered in the state plan: Home Health (Attachment 3.1.AͲ page 12c) An advanced practice registered nurse who is working in accordance with State law, or a physician assistant who is working in accordance with State law may: (1) order home health services; (2) establish and periodically review a plan of care for home health services (e.g., sign the plan of care), (3) certify and reͲcertify that the patient is eligible for home health services. Personal Care (Attachment 3.1.AͲ page 18ee, 18f and 18g) 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. Allow flexibility to deliver personal care services not in accordance with a service plan approved by the state. Providers able to meet the needs or participants may deliver any personal care task deemed necessary to protect the health and welfare of the participant, within the authorized unit limit, even if the specific task is not listed in the plan of care. Authorized nurse supervisory visits may be provided through telehealth, if based on professional judgment, the service can be appropriately provided. Authorized nurse visits may be performed by graduate nurses. A graduate nurse may provide services until receipt of the results of the first licensure examination taken by the graduate nurse or until ninety (90) days after graduation, whichever comes first. 3. ___X__ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe. Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Please describe. Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multiͲsource drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology: a. _____ Published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ b. _____ Other: Describe methodology here. Increases to state plan payment methodologies: 2. _____ The agency increases payment rates for the following services: Please list all that apply. 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. a. _____ Payment increases are targeted based on the following criteria: Please describe criteria. b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: Please describe. ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. telehealth; Describe telehealth payment variation. d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. __X___ Other payment changes: Please describe. Personal Care Services (4.19ͲB page 4a) Agency Model: The total monthly payment made on behalf of an individual may exceed 60% of the average monthly statewide cost for care in a nursing institution (excluding state mental intermediate care facilities), and the total monthly payment for an individual eligible for advanced personal care may exceed 100% of the average monthly statewide cost for care in a nursing institution (excluding state mental intermediate care facilities) for the following reasons: *for participants receiving services in a residential care facility or assisted living facility to receive three additional units per day to comply with CDC guidelines of no congregate dining, participants may only go above the respective cost maximum by the amount of units authorized for this purpose; and *for participants receiving 20 units of telehealth personal care services in order to ensure their health, safety and welfare during the emergency situation, participants may only go above the respective cost maximum by the amount of units authorized for this purpose. Consumer Directed Model: The total monthly payment for personal care assistance for individuals may exceed 60% of the average monthly statewide cost for care in a nursing institution (excluding state mental intermediate care facilities) for the following reason: *for participants receiving 20 units of telehealth personal care services in order to ensure their health, safety and welfare during the emergency situation, participants may only go above the 60% cost maximum by the amount of units authorized for this purpose Section F – PostͲEligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information Personal Care (Agency Model) and Personal Care Assistance (Consumer Directed Services) All evaluations, assessments, and person centered care plan meeting completed by DSDS or designated providers assessors shall be conducted via telephone. Required forms and other necessary documents shall be discussed with HCBS participants or their designee via telephone. Participant or designee acknowledgment shall be accepted verbally by telephone for all documents/ forms. Verbal signatures must be documented with the acknowledging party’s name with a case note: “via telephone.” As needed, reevaluation and reassessments along with care plans may be extended for up to one year past the due date. For agency model personal care, family members who do not live in the same residence and are not legally responsible individuals, spouses or legal guardians, may provide services when no other care giver is available and must be employed by or contracted with a Medicaid HCBS contracted provider. Training requirements are suspended for personal care and advanced personal care aides. Providers are expected to train each individual on the personͲspecific needs of each participant they will begin serving via telephone or other means. The training must include information on participant rights and all information regarding abuse, neglect and exploitation of participants and the importance of reporting fraudulent activities to the State. 3DJH
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TN: ___20Ͳ0012_____________ Approval Date: _:ƵŶĞ ϭϳ͕ ϮϬϮϬ Supersedes TN: __new______________ 1 Effective Date: March 1, 2020 This SPA is in addition to Disaster Relief SPA 20-0013, approved on May 1, 2020 and does not supersede anything approved in that SPA, with the exception of Section C – Premiums and Cost Sharing, item 1. 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 0938Ͳ1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. 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 C4Ͳ26Ͳ05, Baltimore, Maryland 21244Ͳ1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410Ͳ786Ͳ3870. 3DJH
(spa)(mo-20-0013)(approval-document)Missouri Medicaid SPA MO-20-0013: Approval Document (approved May 4, 2020, effective March 1, 2020)#
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Table of Contents State/Territory Name: Missouri State Plan Amendment (SPA) #: 20-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May 4, 2020 Jennifer Tidball Acting Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, Missouri 65102 Re: Missouri State Plan Amendment (SPA) 20-0013 Dear Ms. Tidball: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number MO 20-0013. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions.
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e conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Missouri’s Medicaid SPA Transmittal Number 20-0013 is approved effective March 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Deborah Read at 816-426-6363 or by email at Deborah.read@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Missouri and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello - S Digitally signed by Anne M. Costello -S Date: 2020.05.04 11:30:31 -04'00'
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SEAVICES OMB He. 0505-0109 1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF 20. 0 0 + 3INO STATE PLAN MATERIAL —— — — — — FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES March 1, 2020 5S. TYPE OF PLAN MATERIAL (Check Ong) (1 NEW STATE PLAN [ AMENDMENT TO BE CONSIDERED AS NEW PLAN [) AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT Section 1135 of the Social Security Act; Title XIX of the Soclal Security Act | a. FFY 2% S 39.455.981 b. FFY 2021 $ Unknown 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Section 7.4, Pages 90-98. OR ATTACHMENT (if Applicable) New.
10. SUBJECT OF AMENDMENT
COVID-19 flexibility, Fiscal impact represents first quarter of additional federal costs only. !f extended beyond June 30, 2020, fiscal impact would increase in future quarters due to additional individuals remaining eligible for Medicaid services.
71. GOVERNOR'S REVIEW (Check One)
v GOVERNOR'S OFFICE REPORTED NO COMMENT S (Lt OTHER, AS SPECIFIED (] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
AL 76. RETURN TO MO HealthNet Division
P.O. Box 6500 Jefferson City, MO 65102
“ennlte— &@. Tidball 7
' Act ing. D weetcor 15. DATE SUBMEF ia} SOR. 2006
FOR REGIONAL OFFICE USE ONLY
17, DATE RECEIVED 18. DATE APPROVED April 15, 2020 May 4, 2020 PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL M. March 1, 2020 Anne M. Costello -S ésmsio:s 7M 21. TYPED NAME 22. TITLE : Anne Marie Costello Deputy Director, CMCS 23, REMARKS
FORM CMS-$79 (07/82) instructions on Back
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^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ DŝƐƐŽƵƌŝ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ĞĐƚŝŽŶ ϳ ʹ 'ĞŶĞƌĂů WƌŽǀŝƐŝŽŶƐ ϳ͘ϰ͘ DĞĚŝĐĂŝĚ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ĨŽƌ ƚŚĞ Ks/Ͳϭϵ EĂƚŝŽŶĂů ŵĞƌŐĞŶĐLJ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƚŚĞ WƌĞƐŝĚĞŶƚ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ŝƐƐƵĞĚ Ă ƉƌŽĐůĂŵĂƚŝŽŶ ƚŚĂƚ ƚŚĞ Ks/Ͳϭϵ ŽƵƚďƌĞĂŬ ŝŶ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĐŽŶƐƚŝƚƵƚĞƐ Ă ŶĂƚŝŽŶĂů ĞŵĞƌŐĞŶĐLJ ďLJ ƚŚĞ ĂƵƚŚŽƌŝƚŝĞƐ ǀĞƐƚĞĚ ŝŶ Śŝŵ ďLJ ƚŚĞ ŽŶƐƚŝƚƵƚŝŽŶ ĂŶĚ ƚŚĞ ůĂǁƐ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ͕ ŝŶĐůƵĚŝŶŐ ƐĞĐƚŝŽŶƐ ϮϬϭ ĂŶĚ ϯϬϭ ŽĨ ƚŚĞ EĂƚŝŽŶĂů
ŵĞƌŐĞŶĐŝĞƐ Đƚ ;ϱϬ h͘^͘͘ ϭϲϬϭ Ğƚ ƐĞƋ͘Ϳ͕ ĂŶĚ ĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϭϯϱ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ ;ĐƚͿ͘ KŶ DĂƌĐŚ ϭϯ͕ ϮϬϮϬ͕ ƉƵƌƐƵĂŶƚ ƚŽ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ ŽĨ ƚŚĞ Đƚ͕ ƚŚĞ ^ĞĐƌĞƚĂƌLJ ŽĨ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĞƉĂƌƚŵĞŶƚ ŽĨ ,ĞĂůƚŚ ĂŶĚ ,ƵŵĂŶ ^ĞƌǀŝĐĞƐ ŝŶǀŽŬĞĚ ŚŝƐ ĂƵƚŚŽƌŝƚLJ ƚŽ ǁĂŝǀĞ Žƌ ŵŽĚŝĨLJ ĐĞƌƚĂŝŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ŽĨ ƚŝƚůĞƐ ys///͕ y/y͕ ĂŶĚ yy/ ŽĨ ƚŚĞ Đƚ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ ĐŽŶƐĞƋƵĞŶĐĞƐ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ƚŽ ƚŚĞ ĞdžƚĞŶƚ ŶĞĐĞƐƐĂƌLJ͕ ĂƐ ĚĞƚĞƌŵŝŶĞĚ ďLJ ƚŚĞ ĞŶƚĞƌƐ ĨŽƌ DĞĚŝĐĂƌĞ Θ DĞĚŝĐĂŝĚ ^ĞƌǀŝĐĞƐ ;D^Ϳ͕ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ƐƵĨĨŝĐŝĞŶƚ ŚĞĂůƚŚ ĐĂƌĞ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂƌĞ ĂǀĂŝůĂďůĞ ƚŽ ŵĞĞƚ ƚŚĞ ŶĞĞĚƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĞŶƌŽůůĞĚ ŝŶ ƚŚĞ ƌĞƐƉĞĐƚŝǀĞ ƉƌŽŐƌĂŵƐ ĂŶĚ ƚŽ ĞŶƐƵƌĞ ƚŚĂƚ ŚĞĂůƚŚ ĐĂƌĞ ƉƌŽǀŝĚĞƌƐ ƚŚĂƚ ĨƵƌŶŝƐŚ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ŝŶ ŐŽŽĚ ĨĂŝƚŚ͕ ďƵƚ ĂƌĞ ƵŶĂďůĞ ƚŽ ĐŽŵƉůLJ ǁŝƚŚ ŽŶĞ Žƌ ŵŽƌĞ ŽĨ ƐƵĐŚ ƌĞƋƵŝƌĞŵĞŶƚƐ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ Ks/Ͳϭϵ ƉĂŶĚĞŵŝĐ͕ ŵĂLJ ďĞ ƌĞŝŵďƵƌƐĞĚ ĨŽƌ ƐƵĐŚ ŝƚĞŵƐ ĂŶĚ ƐĞƌǀŝĐĞƐ ĂŶĚ ĞdžĞŵƉƚĞĚ ĨƌŽŵ ƐĂŶĐƚŝŽŶƐ ĨŽƌ ƐƵĐŚ ŶŽŶĐŽŵƉůŝĂŶĐĞ͕ ĂďƐĞŶƚ ĂŶLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶ ŽĨ ĨƌĂƵĚ Žƌ ĂďƵƐĞ͘ dŚŝƐ ĂƵƚŚŽƌŝƚLJ ƚŽŽŬ ĞĨĨĞĐƚ ĂƐ ŽĨ ϲWD
ĂƐƚĞƌŶ ^ƚĂŶĚĂƌĚ dŝŵĞ ŽŶ DĂƌĐŚ ϭϱ͕ ϮϬϮϬ͕ ǁŝƚŚ Ă ƌĞƚƌŽĂĐƚŝǀĞ ĞĨĨĞĐƚŝǀĞ ĚĂƚĞ ŽĨ DĂƌĐŚ ϭ͕ ϮϬϮϬ͘ dŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ ǁŝůů ƚĞƌŵŝŶĂƚĞ͕ ĂŶĚ ǁĂŝǀĞƌƐ ǁŝůů ŶŽ ůŽŶŐĞƌ ďĞ ĂǀĂŝůĂďůĞ͕ ƵƉŽŶ ƚĞƌŵŝŶĂƚŝŽŶ ŽĨ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ ŝŶĐůƵĚŝŶŐ ĂŶLJ ĞdžƚĞŶƐŝŽŶƐ͘ dŚĞ ^ƚĂƚĞ DĞĚŝĐĂŝĚ ĂŐĞŶĐLJ ;ĂŐĞŶĐLJͿ ƐĞĞŬƐ ƚŽ ŝŵƉůĞŵĞŶƚ ƚŚĞ ƉŽůŝĐŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͕ ǁŚŝĐŚ ĂƌĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ƚŚĞ ƉŽůŝĐŝĞƐ ĂŶĚ ƉƌŽĐĞĚƵƌĞƐ ŽƚŚĞƌǁŝƐĞ ĂƉƉůŝĞĚ ƵŶĚĞƌ ƚŚĞ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĚƵƌŝŶŐ ƚŚĞ ƉĞƌŝŽĚ ŽĨ ƚŚĞ WƌĞƐŝĚĞŶƚŝĂů ĂŶĚ ^ĞĐƌĞƚĂƌŝĂů ĞŵĞƌŐĞŶĐLJ ĚĞĐůĂƌĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ Ks/Ͳϭϵ ŽƵƚďƌĞĂŬ ;Žƌ ĂŶLJ ƌĞŶĞǁĂůƐ ƚŚĞƌĞŽĨͿ͕ Žƌ ĨŽƌ ĂŶLJ ƐŚŽƌƚĞƌ ƉĞƌŝŽĚ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ EKd ͗ ^ƚĂƚĞƐ ŵĂLJ ŶŽƚ ĞůĞĐƚ Ă ƉĞƌŝŽĚ ůŽŶŐĞƌ ƚŚĂŶ ƚŚĞ WƌĞƐŝĚĞŶƚŝĂů Žƌ ^ĞĐƌĞƚĂƌŝĂů ĞŵĞƌŐĞŶĐLJ ĚĞĐůĂƌĂƚŝŽŶ ;Žƌ ĂŶLJ ƌĞŶĞǁĂů ƚŚĞƌĞŽĨͿ͘ ^ƚĂƚĞƐ ŵĂLJ ŶŽƚ ƉƌŽƉŽƐĞ ĐŚĂŶŐĞƐ ŽŶ ƚŚŝƐ ƚĞŵƉůĂƚĞ ƚŚĂƚ ƌĞƐƚƌŝĐƚ Žƌ ůŝŵŝƚ ƉĂLJŵĞŶƚ͕ ƐĞƌǀŝĐĞƐ͕ Žƌ ĞůŝŐŝďŝůŝƚLJ͕ Žƌ ŽƚŚĞƌǁŝƐĞ ďƵƌĚĞŶ ďĞŶĞĨŝĐŝĂƌŝĞƐ ĂŶĚ ƉƌŽǀŝĚĞƌƐ͘ ZĞƋƵĞƐƚ ĨŽƌ tĂŝǀĞƌƐ ƵŶĚĞƌ ^ĞĐƚŝŽŶ ϭϭϯϱ ͺͺz dŚĞ ĂŐĞŶĐLJ ƐĞĞŬƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƵŶĚĞƌ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ;ϭͿ;Ϳ ĂŶĚͬŽƌ ƐĞĐƚŝŽŶ ϭϭϯϱ;ďͿ;ϱͿ ŽĨ ƚŚĞ Đƚ͗ Ă͘ ͺͺzͺͺͺ ^W ƐƵďŵŝƐƐŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚ ƚŽ ƐƵďŵŝƚ ƚŚĞ ^W ďLJ DĂƌĐŚ ϯϭ͕ ϮϬϮϬ͕ ƚŽ ŽďƚĂŝŶ Ă ^W ĞĨĨĞĐƚŝǀĞ ĚĂƚĞ ĚƵƌŝŶŐ ƚŚĞ ĨŝƌƐƚ ĐĂůĞŶĚĂƌ ƋƵĂƌƚĞƌ ŽĨ ϮϬϮϬ͕ ƉƵƌƐƵĂŶƚ ƚŽ ϰϮ &Z ϰϯϬ͘ϮϬ͘ ď͘ ͺͺzͺͺͺ WƵďůŝĐ ŶŽƚŝĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ǁĂŝǀĞƌ ŽĨ ƉƵďůŝĐ ŶŽƚŝĐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ƚŚĂƚ ǁŽƵůĚ ŽƚŚĞƌǁŝƐĞ ďĞ ĂƉƉůŝĐĂďůĞ ƚŽ ƚŚŝƐ ^W ƐƵďŵŝƐƐŝŽŶ͘ dŚĞƐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚŽƐĞ ƐƉĞĐŝĨŝĞĚ ŝŶ ϰϮ &Z ϰϰϬ͘ϯϴϲ ;ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐͿ͕ ϰϮ &Z ϰϰϳ͘ϱϳ;ĐͿ ;ƉƌĞŵŝƵŵƐ ĂŶĚ ĐŽƐƚ ƐŚĂƌŝŶŐͿ͕ ĂŶĚ ϰϮ &Z ϰϰϳ͘ϮϬϱ ;ƉƵďůŝĐ ŶŽƚŝĐĞ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ƐƚĂƚĞǁŝĚĞ ŵĞƚŚŽĚƐ ĂŶĚ ƐƚĂŶĚĂƌĚƐ ĨŽƌ ƐĞƚƚŝŶŐ ƉĂLJŵĞŶƚ ƌĂƚĞƐͿ͘ ϮϬͲϬϬϭϯ ϱͬϰͬϮϬ ϯͬϭͬϮϬ E t
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^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ DŝƐƐŽƵƌŝ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Đ͘ ͺͺͺͺͺ dƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƌĞƋƵŝƌĞŵĞŶƚƐ ʹ ƚŚĞ ĂŐĞŶĐLJ ƌĞƋƵĞƐƚƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŽĨ ƚƌŝďĂů ĐŽŶƐƵůƚĂƚŝŽŶ ƚŝŵĞůŝŶĞƐ ƐƉĞĐŝĨŝĞĚ ŝŶ ŝŶƐĞƌƚ ŶĂŵĞ ŽĨ ƐƚĂƚĞ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͕ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŵŽĚŝĨŝĐĂƚŝŽŶƐ ƚŽ ƚŚĞ ƚŝŵĞůŝŶĞ͘ ^ĞĐƚŝŽŶ ʹ ůŝŐŝďŝůŝƚLJ ϭ͘ ͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ŐƌŽƵƉƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ Žƌ ϭϵϬϮ;ĂͿ;ϭϬͿ;ĐͿ ŽĨ ƚŚĞ Đƚ͘ dŚŝƐ ŵĂLJ ŝŶĐůƵĚĞ ƚŚĞ ŶĞǁ ŽƉƚŝŽŶĂů ŐƌŽƵƉ ĚĞƐĐƌŝďĞĚ Ăƚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yy///Ϳ ĂŶĚ ϭϵϬϮ;ƐƐͿ ŽĨ ƚŚĞ Đƚ ƉƌŽǀŝĚŝŶŐ ĐŽǀĞƌĂŐĞ ĨŽƌ ƵŶŝŶƐƵƌĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĨƵƌŶŝƐŚĞƐ ŵĞĚŝĐĂů ĂƐƐŝƐƚĂŶĐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉŽƉƵůĂƚŝŽŶƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘Ϯϭϴ͗ Ă͘ ͺͺͺͺͺ ůů ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĚĞƐĐƌŝďĞĚ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;yyͿ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͲŽƌͲ ď͘ ͺͺͺͺͺ /ŶĚŝǀŝĚƵĂůƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ƐĞĐƚŝŽŶ ϭϵϬϱ;ĂͿ ŽĨ ƚŚĞ Đƚ͗ /ŶĐŽŵĞ ƐƚĂŶĚĂƌĚ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƉƉůŝĞƐ ůĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ďĂƐĞĚ ŽŶ ŵŽĚŝĨŝĞĚ ĂĚũƵƐƚĞĚ ŐƌŽƐƐ ŝŶĐŽŵĞ ;D'/Ϳ ĂƐ ĨŽůůŽǁƐ͘ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ŝŶĐŽŵĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ >ĞƐƐ ƌĞƐƚƌŝĐƚŝǀĞ ƌĞƐŽƵƌĐĞ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ ϮϬͲϬϬϭϯ ϱͬϰͬϮϬ ϯͬϭͬϮϬ E t
(spa)(mo-20-0013)(approval-document)(page-7)Page 7#
^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ DŝƐƐŽƵƌŝ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ϰ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶƐŝĚĞƌƐ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĂƌĞ ĞǀĂĐƵĂƚĞĚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ůĞĂǀĞ ƚŚĞ ƐƚĂƚĞ ĨŽƌ ŵĞĚŝĐĂů ƌĞĂƐŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͕ Žƌ ǁŚŽ ĂƌĞ ŽƚŚĞƌǁŝƐĞ ĂďƐĞŶƚ ĨƌŽŵ ƚŚĞ ƐƚĂƚĞ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ ĂŶĚ ǁŚŽ ŝŶƚĞŶĚ ƚŽ ƌĞƚƵƌŶ ƚŽ ƚŚĞ ƐƚĂƚĞ͕ ƚŽ ĐŽŶƚŝŶƵĞ ƚŽ ďĞ ƌĞƐŝĚĞŶƚƐ ŽĨ ƚŚĞ ƐƚĂƚĞ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϰϬϯ;ũͿ;ϯͿ͘ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ DĞĚŝĐĂŝĚ ĐŽǀĞƌĂŐĞ ƚŽ ƚŚĞ ĨŽůůŽǁŝŶŐ ŝŶĚŝǀŝĚƵĂůƐ ůŝǀŝŶŐ ŝŶ ƚŚĞ ƐƚĂƚĞ͕ ǁŚŽ ĂƌĞ ŶŽŶͲƌĞƐŝĚĞŶƚƐ͗ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƉƌŽǀŝĚĞƐ ĨŽƌ ĂŶ ĞdžƚĞŶƐŝŽŶ ŽĨ ƚŚĞ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĨŽƌ ŶŽŶͲ ĐŝƚŝnjĞŶƐ ĚĞĐůĂƌŝŶŐ ƚŽ ďĞ ŝŶ Ă ƐĂƚŝƐĨĂĐƚŽƌLJ ŝŵŵŝŐƌĂƚŝŽŶ ƐƚĂƚƵƐ͕ ŝĨ ƚŚĞ ŶŽŶͲĐŝƚŝnjĞŶ ŝƐ ŵĂŬŝŶŐ Ă ŐŽŽĚ ĨĂŝƚŚ ĞĨĨŽƌƚ ƚŽ ƌĞƐŽůǀĞ ĂŶLJ ŝŶĐŽŶƐŝƐƚĞŶĐĞƐ Žƌ ŽďƚĂŝŶ ĂŶLJ ŶĞĐĞƐƐĂƌLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ͕ Žƌ ƚŚĞ ĂŐĞŶĐLJ ŝƐ ƵŶĂďůĞ ƚŽ ĐŽŵƉůĞƚĞ ƚŚĞ ǀĞƌŝĨŝĐĂƚŝŽŶ ƉƌŽĐĞƐƐ ǁŝƚŚŝŶ ƚŚĞ ϵϬͲĚĂLJ ƌĞĂƐŽŶĂďůĞ ŽƉƉŽƌƚƵŶŝƚLJ ƉĞƌŝŽĚ ĚƵĞ ƚŽ ƚŚĞ ĚŝƐĂƐƚĞƌ Žƌ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐLJ͘ ^ĞĐƚŝŽŶ ʹ ŶƌŽůůŵĞŶƚ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĞůĞĐƚƐ ƚŽ ĂůůŽǁ ŚŽƐƉŝƚĂůƐ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚĚŝƚŝŽŶĂů ƐƚĂƚĞ ƉůĂŶ ƉŽƉƵůĂƚŝŽŶƐ͕ Žƌ ĨŽƌ ƉŽƉƵůĂƚŝŽŶƐ ŝŶ ĂŶ ĂƉƉƌŽǀĞĚ ƐĞĐƚŝŽŶ ϭϭϭϱ ĚĞŵŽŶƐƚƌĂƚŝŽŶ͕ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϰϳͿ;Ϳ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϭϭϭϬ͕ ƉƌŽǀŝĚĞĚ ƚŚĂƚ ƚŚĞ ĂŐĞŶĐLJ ŚĂƐ ĚĞƚĞƌŵŝŶĞĚ ƚŚĂƚ ƚŚĞ ŚŽƐƉŝƚĂů ŝƐ ĐĂƉĂďůĞ ŽĨ ŵĂŬŝŶŐ ƐƵĐŚ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĂƉƉůŝĐĂďůĞ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐͬƉŽƉƵůĂƚŝŽŶƐ ĂŶĚ ĂŶLJ ĐŚĂŶŐĞƐ ƚŽ ƌĞĂƐŽŶĂďůĞ ůŝŵŝƚĂƚŝŽŶƐ͕ ƉĞƌĨŽƌŵĂŶĐĞ ƐƚĂŶĚĂƌĚƐ Žƌ ŽƚŚĞƌ ĨĂĐƚŽƌƐ͘ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ŝƚƐĞůĨ ĂƐ Ă ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚLJ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĂŶLJ ůŝŵŝƚĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ƉŽƉƵůĂƚŝŽŶƐ ŝŶĐůƵĚĞĚ Žƌ ƚŚĞ ŶƵŵďĞƌ ŽĨ ĂůůŽǁĂďůĞ W
ƉĞƌŝŽĚƐ͘ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĚĞƐŝŐŶĂƚĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĞŶƚŝƚŝĞƐ ĂƐ ƋƵĂůŝĨŝĞĚ ĞŶƚŝƚŝĞƐ ĨŽƌ ƉƵƌƉŽƐĞƐ ŽĨ ŵĂŬŝŶŐ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ Žƌ ĂĚĚƐ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂƐ ĚĞƐĐƌŝďĞĚ ďĞůŽǁ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶƐ ϭϵϮϬ͕ ϭϵϮϬ͕ ϭϵϮϬ͕ ĂŶĚ ϭϵϮϬ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z WĂƌƚ ϰϯϱ ^ƵďƉĂƌƚ >͘ /ŶĚŝĐĂƚĞ ŝĨ ĂŶLJ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ ĂƌĞ ƉĞƌŵŝƚƚĞĚ ƚŽ ŵĂŬĞ ƉƌĞƐƵŵƉƚŝǀĞ ĞůŝŐŝďŝůŝƚLJ ĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽŶůLJ ĨŽƌ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ͘ ϮϬͲϬϬϭϯ ϱͬϰͬϮϬ ϯͬϭͬϮϬ E t
(spa)(mo-20-0013)(approval-document)(page-8)Page 8#
^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ DŝƐƐŽƵƌŝ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĚĞƐŝŐŶĂƚĞĚ ĞŶƚŝƚŝĞƐ Žƌ ĂĚĚŝƚŝŽŶĂů ƉŽƉƵůĂƚŝŽŶƐ ĂŶĚ ĂŶLJ ůŝŵŝƚĂƚŝŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ƐƉĞĐŝĨŝĞĚ ƉŽƉƵůĂƚŝŽŶƐ Žƌ ŶƵŵďĞƌ ŽĨ ĂůůŽǁĂďůĞ W ƉĞƌŝŽĚƐ͘ ϰ͘ ͺͺzͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚŽƉƚƐ Ă ƚŽƚĂů ŽĨ ͺͺϭϮ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ĐŽŶƚŝŶƵŽƵƐ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ĐŚŝůĚƌĞŶ ƵŶĚĞƌ ĂŐĞ ĞŶƚĞƌ ĂŐĞ ͺͺ ϭϵͺͺ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ĂŐĞ ϭϵͿ ƌĞŐĂƌĚůĞƐƐ ŽĨ ĐŚĂŶŐĞƐ ŝŶ ĐŝƌĐƵŵƐƚĂŶĐĞƐ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ƐĞĐƚŝŽŶ ϭϵϬϮ;ĞͿ;ϭϮͿ ŽĨ ƚŚĞ Đƚ ĂŶĚ ϰϮ &Z ϰϯϱ͘ϵϮϲ͘ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĐŽŶĚƵĐƚƐ ƌĞĚĞƚĞƌŵŝŶĂƚŝŽŶƐ ŽĨ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ĞdžĐĞƉƚĞĚ ĨƌŽŵ D'/Ͳ ďĂƐĞĚ ĨŝŶĂŶĐŝĂů ŵĞƚŚŽĚŽůŽŐŝĞƐ ƵŶĚĞƌ ϰϮ &Z ϰϯϱ͘ϲϬϯ;ũͿ ŽŶĐĞ ĞǀĞƌLJ ͺͺͺͺͺ ŵŽŶƚŚƐ ;ŶŽƚ ƚŽ ĞdžĐĞĞĚ ϭϮ ŵŽŶƚŚƐͿ ŝŶ ĂĐĐŽƌĚĂŶĐĞ ǁŝƚŚ ϰϮ &Z ϰϯϱ͘ϵϭϲ;ďͿ͘ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ƚŽ ƐƵƉƉŽƌƚ ĞŶƌŽůůŵĞŶƚ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ Žƌ ĨŽƌ ĂĨĨĞĐƚĞĚ ŝŶĚŝǀŝĚƵĂůƐ ;Ă ĐŽƉLJ ŽĨ ƚŚĞ ƐŝŵƉůŝĨŝĞĚ ĂƉƉůŝĐĂƚŝŽŶ;ƐͿ ŚĂƐ ďĞĞŶ ƐƵďŵŝƚƚĞĚ ƚŽ D^Ϳ͘ Ă͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ ĂƉƉůŝĐĂƚŝŽŶ͘ ď͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƐĞƐ Ă ƐŝŵƉůŝĨŝĞĚ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ͘ Đ͘ ͺͺͺͺͺ dŚĞ ƐŝŵƉůŝĨŝĞĚ ƉĂƉĞƌ Žƌ ŽŶůŝŶĞ ĂƉƉůŝĐĂƚŝŽŶ ŝƐ ŵĂĚĞ ĂǀĂŝůĂďůĞ ĨŽƌ ƵƐĞ ŝŶ ĐĂůůͲĐĞŶƚĞƌƐ Žƌ ŽƚŚĞƌ ƚĞůĞƉŚŽŶĞ ĂƉƉůŝĐĂƚŝŽŶƐ ŝŶ ĂĨĨĞĐƚĞĚ ĂƌĞĂƐ͘ ^ĞĐƚŝŽŶ ʹ WƌĞŵŝƵŵƐ ĂŶĚ ŽƐƚ ^ŚĂƌŝŶŐ ϭ͘ z dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĚĞĚƵĐƚŝďůĞƐ͕ ĐŽƉĂLJŵĞŶƚƐ͕ ĐŽŝŶƐƵƌĂŶĐĞ͕ ĂŶĚ ŽƚŚĞƌ ĐŽƐƚ ƐŚĂƌŝŶŐ ĐŚĂƌŐĞƐ ĂƐ ĨŽůůŽǁƐ͗ dŚĞ ƐƚĂƚĞ ǁĂŝǀĞƐ ĐŽƐƚ ƐŚĂƌŝŶŐ ĨŽƌ ƚĞƐƚŝŶŐ ƐĞƌǀŝĐĞƐ ;ŝŶĐůƵĚŝŶŐ ŝŶ ǀŝƚƌŽ ĚŝĂŐŶŽƐƚŝĐ ƉƌŽĚƵĐƚƐͿ͕ ƚĞƐƚŝŶŐͲ ƌĞůĂƚĞĚ ƐĞƌǀŝĐĞƐ͕ ĂŶĚ ƚƌĞĂƚŵĞŶƚƐ ĨŽƌ Ks/Ͳϭϵ͕ ŝŶĐůƵĚŝŶŐ ǀĂĐĐŝŶĞƐ͕ ƐƉĞĐŝĂůŝnjĞĚ ĞƋƵŝƉŵĞŶƚ ĂŶĚ ƚŚĞƌĂƉŝĞƐ ;ŝŶĐůƵĚŝŶŐ ĚƌƵŐƐͿ͕ ĨŽƌ ĂŶLJ ƋƵĂƌƚĞƌ ŝŶ ǁŚŝĐŚ ƚŚĞ ŝŶĐƌĞĂƐĞĚ &DW ŝƐ ĐůĂŝŵĞĚ͘ Ϯ͘ ͺͺ ͺͺͺ dŚĞ ĂŐĞŶĐLJ ƐƵƐƉĞŶĚƐ ĞŶƌŽůůŵĞŶƚ ĨĞĞƐ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ͗ Ă͘ ͺͺͺͺͺ ůů ďĞŶĞĨŝĐŝĂƌŝĞƐ ď͘ ͺͺ dŚĞ ĨŽůůŽǁŝŶŐ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ĐĂƚĞŐŽƌŝĐĂů ƉŽƉƵůĂƚŝŽŶƐ͗ WůĞĂƐĞ ůŝƐƚ ƚŚĞ ĂƉƉůŝĐĂďůĞ ĞůŝŐŝďŝůŝƚLJ ŐƌŽƵƉƐ Žƌ ƉŽƉƵůĂƚŝŽŶƐ͘ ϯ͘ z dŚĞ ĂŐĞŶĐLJ ĂůůŽǁƐ ǁĂŝǀĞƌ ŽĨ ƉĂLJŵĞŶƚ ŽĨ ƚŚĞ ĞŶƌŽůůŵĞŶƚ ĨĞĞ͕ ƉƌĞŵŝƵŵƐ ĂŶĚ ƐŝŵŝůĂƌ ĐŚĂƌŐĞƐ ĨŽƌ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ ϮϬͲϬϬϭϯ ϱͬϰͬϮϬ ϯͬϭͬϮϬ E t
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^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ DŝƐƐŽƵƌŝ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ WůĞĂƐĞ ƐƉĞĐŝĨLJ ƚŚĞ ƐƚĂŶĚĂƌĚ;ƐͿ ĂŶĚͬŽƌ ĐƌŝƚĞƌŝĂ ƚŚĂƚ ƚŚĞ ƐƚĂƚĞ ǁŝůů ƵƐĞ ƚŽ ĚĞƚĞƌŵŝŶĞ ƵŶĚƵĞ ŚĂƌĚƐŚŝƉ͘ /Ŷ ĐŽŵƉůŝĂŶĐĞ ǁŝƚŚ ƚŚĞ ŵĂŝŶƚĞŶĂŶĐĞ ŽĨ ĞĨĨŽƌƚ ƌĞƋƵŝƌĞŵĞŶƚƐ͕ DŝƐƐŽƵƌŝ ŝƐ ŶŽƚ ǁĂŝǀŝŶŐ ƚŚĞ ƉƌĞŵŝƵŵ ŽďůŝŐĂƚŝŽŶ͖ ŚŽǁĞǀĞƌ͕ ŝĨ ƚŚĞ ƉƌĞŵŝƵŵ ŽďůŝŐĂƚŝŽŶ ŝƐ ŶŽƚ ŵĞƚ ĚƵƌŝŶŐ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ͕ DŝƐƐŽƵƌŝ ǁŝůů ŶŽƚ ĚŝƐĐŽŶƚŝŶƵĞ ĐŽǀĞƌĂŐĞ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ŐƌŽƵƉƐ͗ ϭ͘ dŝĐŬĞƚ ƚŽ tŽƌŬ ĂŶĚ tŽƌŬ /ŶĐĞŶƚŝǀĞƐ /ŵƉƌŽǀĞŵĞŶƚ Đƚ ;dtt//Ϳ ĂƐŝĐ ŽǀĞƌĂŐĞ 'ƌŽƵƉ͕ ^ĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;ysͿ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ͘ Ϯ͘ dtt// DĞĚŝĐĂů /ŵƉƌŽǀĞŵĞŶƚ 'ƌŽƵƉ͕ ^ĞĐƚŝŽŶ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ;ŝŝͿ;ys/Ϳ ŽĨ ƚŚĞ ^ŽĐŝĂů ^ĞĐƵƌŝƚLJ Đƚ͘ ^ĞĐƚŝŽŶ Ͳ ĞŶĞĨŝƚƐ ĞŶĞĨŝƚƐ͗ ϭ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂĚĚƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŽƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ŝŶ ŝƚƐ ƐƚĂƚĞ ƉůĂŶ ;ŝŶĐůƵĚĞ ƐĞƌǀŝĐĞ ĚĞƐĐƌŝƉƚŝŽŶƐ͕ ƉƌŽǀŝĚĞƌ ƋƵĂůŝĨŝĐĂƚŝŽŶƐ͕ ĂŶĚ ůŝŵŝƚĂƚŝŽŶƐ ŽŶ ĂŵŽƵŶƚ͕ ĚƵƌĂƚŝŽŶ Žƌ ƐĐŽƉĞ ŽĨ ƚŚĞ ďĞŶĞĨŝƚͿ͗ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐƵƌƌĞŶƚůLJ ĐŽǀĞƌĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ ƉůĂŶ͗ ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ĂƐƐƵƌĞƐ ƚŚĂƚ ŶĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ Žƌ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ďĞŶĞĨŝƚƐ ĐŽŵƉůLJ ǁŝƚŚ Ăůů ĂƉƉůŝĐĂďůĞ ƐƚĂƚƵƚŽƌLJ ƌĞƋƵŝƌĞŵĞŶƚƐ͕ ŝŶĐůƵĚŝŶŐ ƚŚĞ ƐƚĂƚĞǁŝĚĞŶĞƐƐ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭͿ͕ ĐŽŵƉĂƌĂďŝůŝƚLJ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϭϬͿ;Ϳ͕ ĂŶĚ ĨƌĞĞ ĐŚŽŝĐĞ ŽĨ ƉƌŽǀŝĚĞƌ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƵŶĚ Ăƚ ϭϵϬϮ;ĂͿ;ϮϯͿ͘ ϰ͘ ͺͺͺͺͺ ƉƉůŝĐĂƚŝŽŶ ƚŽ ůƚĞƌŶĂƚŝǀĞ ĞŶĞĨŝƚ WůĂŶƐ ;WͿ͘ dŚĞ ƐƚĂƚĞ ĂĚŚĞƌĞƐ ƚŽ Ăůů W ƉƌŽǀŝƐŝŽŶƐ ŝŶ ϰϮ &Z WĂƌƚ ϰϰϬ͕ ^ƵďƉĂƌƚ ͘ dŚŝƐ ƐĞĐƚŝŽŶ ŽŶůLJ ĂƉƉůŝĞƐ ƚŽ ƐƚĂƚĞƐ ƚŚĂƚ ŚĂǀĞ ĂŶ ĂƉƉƌŽǀĞĚ W;ƐͿ͘ Ǥ ̴̴̴̴̴ Ȁ Ǥ Ǥ ̴̴̴̴̴ ϮϬͲϬϬϭϯ ϱͬϰͬϮϬ ϯͬϭͬϮϬ E t
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^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ DŝƐƐŽƵƌŝ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ȁ ǡ ǣ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ dĞůĞŚĞĂůƚŚ͗ ϱ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ƵƚŝůŝnjĞƐ ƚĞůĞŚĞĂůƚŚ ŝŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĂŶŶĞƌ͕ ǁŚŝĐŚ ŵĂLJ ďĞ ĚŝĨĨĞƌĞŶƚ ƚŚĂŶ ŽƵƚůŝŶĞĚ ŝŶ ƚŚĞ ƐƚĂƚĞ͛Ɛ ĂƉƉƌŽǀĞĚ ƐƚĂƚĞ ƉůĂŶ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ ƌƵŐ ĞŶĞĨŝƚ͗ ϲ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂĚũƵƐƚŵĞŶƚƐ ƚŽ ƚŚĞ ĚĂLJ ƐƵƉƉůLJ Žƌ ƋƵĂŶƚŝƚLJ ůŝŵŝƚ ĨŽƌ ĐŽǀĞƌĞĚ ŽƵƚƉĂƚŝĞŶƚ ĚƌƵŐƐ͘ dŚĞ ĂŐĞŶĐLJ ƐŚŽƵůĚ ŽŶůLJ ŵĂŬĞ ƚŚŝƐ ŵŽĚŝĨŝĐĂƚŝŽŶ ŝĨ ŝƚƐ ĐƵƌƌĞŶƚ ƐƚĂƚĞ ƉůĂŶ ƉĂŐĞƐ ŚĂǀĞ ůŝŵŝƚƐ ŽŶ ƚŚĞ ĂŵŽƵŶƚ ŽĨ ŵĞĚŝĐĂƚŝŽŶ ĚŝƐƉĞŶƐĞĚ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ĐŚĂŶŐĞ ŝŶ ĚĂLJƐ Žƌ ƋƵĂŶƚŝƚŝĞƐ ƚŚĂƚ ĂƌĞ ĂůůŽǁĞĚ ĨŽƌ ƚŚĞ ĞŵĞƌŐĞŶĐLJ ƉĞƌŝŽĚ ĂŶĚ ĨŽƌ ǁŚŝĐŚ ĚƌƵŐƐ͘ ϳ͘ ͺͺͺͺͺ WƌŝŽƌ ĂƵƚŚŽƌŝnjĂƚŝŽŶ ĨŽƌ ŵĞĚŝĐĂƚŝŽŶƐ ŝƐ ĞdžƉĂŶĚĞĚ ďLJ ĂƵƚŽŵĂƚŝĐ ƌĞŶĞǁĂů ǁŝƚŚŽƵƚ ĐůŝŶŝĐĂů ƌĞǀŝĞǁ͕ Žƌ ƚŝŵĞͬƋƵĂŶƚŝƚLJ ĞdžƚĞŶƐŝŽŶƐ͘ ϴ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĂLJŵĞŶƚ ĂĚũƵƐƚŵĞŶƚ ƚŽ ƚŚĞ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞ ǁŚĞŶ ĂĚĚŝƚŝŽŶĂů ĐŽƐƚƐ ĂƌĞ ŝŶĐƵƌƌĞĚ ďLJ ƚŚĞ ƉƌŽǀŝĚĞƌƐ ĨŽƌ ĚĞůŝǀĞƌLJ͘ ^ƚĂƚĞƐ ǁŝůů ŶĞĞĚ ƚŽ ƐƵƉƉůLJ ĚŽĐƵŵĞŶƚĂƚŝŽŶ ƚŽ ũƵƐƚŝĨLJ ƚŚĞ ĂĚĚŝƚŝŽŶĂů ĨĞĞƐ͘ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ƚŚĞ ŵĂŶŶĞƌ ŝŶ ǁŚŝĐŚ ƉƌŽĨĞƐƐŝŽŶĂů ĚŝƐƉĞŶƐŝŶŐ ĨĞĞƐ ĂƌĞ ĂĚũƵƐƚĞĚ͘ ϵ͘ z dŚĞ ĂŐĞŶĐLJ ŵĂŬĞƐ ĞdžĐĞƉƚŝŽŶƐ ƚŽ ƚŚĞŝƌ ƉƵďůŝƐŚĞĚ WƌĞĨĞƌƌĞĚ ƌƵŐ >ŝƐƚ ŝĨ ĚƌƵŐ ƐŚŽƌƚĂŐĞƐ ŽĐĐƵƌ͘ dŚŝƐ ǁŽƵůĚ ŝŶĐůƵĚĞ ŽƉƚŝŽŶƐ ĨŽƌ ĐŽǀĞƌŝŶŐ Ă ďƌĂŶĚ ŶĂŵĞ ĚƌƵŐ ƉƌŽĚƵĐƚ ƚŚĂƚ ŝƐ Ă ŵƵůƚŝͲƐŽƵƌĐĞ ĚƌƵŐ ŝĨ Ă ŐĞŶĞƌŝĐ ĚƌƵŐ ŽƉƚŝŽŶ ŝƐ ŶŽƚ ĂǀĂŝůĂďůĞ͘ ^ĞĐƚŝŽŶ ʹ WĂLJŵĞŶƚƐ KƉƚŝŽŶĂů ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ͗ ϭ͘ ͺͺͺͺͺ EĞǁůLJ ĂĚĚĞĚ ďĞŶĞĨŝƚƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^ĞĐƚŝŽŶ ĂƌĞ ƉĂŝĚ ƵƐŝŶŐ ƚŚĞ ĨŽůůŽǁŝŶŐ ŵĞƚŚŽĚŽůŽŐLJ͗ ϮϬͲϬϬϭϯ ϱͬϰͬϮϬ ϯͬϭͬϮϬ E t
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^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ DŝƐƐŽƵƌŝ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ Ǥ ̴̴̴̴̴ Ȃ
ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ Ǥ ̴̴̴̴̴ ǣ ĞƐĐƌŝďĞ ŵĞƚŚŽĚŽůŽŐLJ ŚĞƌĞ͘ /ŶĐƌĞĂƐĞƐ ƚŽ ƐƚĂƚĞ ƉůĂŶ ƉĂLJŵĞŶƚ ŵĞƚŚŽĚŽůŽŐŝĞƐ͗ Ϯ͘ ͺͺͺͺͺ dŚĞ ĂŐĞŶĐLJ ŝŶĐƌĞĂƐĞƐ ƉĂLJŵĞŶƚ ƌĂƚĞƐ ĨŽƌ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐĞƌǀŝĐĞƐ͗ WůĞĂƐĞ ůŝƐƚ Ăůů ƚŚĂƚ ĂƉƉůLJ͘ Ă͘ ͺͺͺͺͺ WĂLJŵĞŶƚ ŝŶĐƌĞĂƐĞƐ ĂƌĞ ƚĂƌŐĞƚĞĚ ďĂƐĞĚ ŽŶ ƚŚĞ ĨŽůůŽǁŝŶŐ ĐƌŝƚĞƌŝĂ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ ĐƌŝƚĞƌŝĂ͘ ď͘ WĂLJŵĞŶƚƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ ƚŚƌŽƵŐŚ͗ Ǥ ̴̴̴̴̴ Ǧ ǣ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ Ǥ ̴̴̴̴̴ Ǥ ZĂƚĞƐ ĂƌĞ ŝŶĐƌĞĂƐĞĚ͗ ͺͺͺͺͺ hŶŝĨŽƌŵůLJ ďLJ ƚŚĞ ĨŽůůŽǁŝŶŐ ƉĞƌĐĞŶƚĂŐĞ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺ dŚƌŽƵŐŚ Ă ŵŽĚŝĨŝĐĂƚŝŽŶ ƚŽ ƉƵďůŝƐŚĞĚ ĨĞĞ ƐĐŚĞĚƵůĞƐ ʹ
ĨĨĞĐƚŝǀĞ ĚĂƚĞ ;ĞŶƚĞƌ ĚĂƚĞ ŽĨ ĐŚĂŶŐĞͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ >ŽĐĂƚŝŽŶ ;ůŝƐƚ ƉƵďůŝƐŚĞĚ ůŽĐĂƚŝŽŶͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺ ϮϬͲϬϬϭϯ ϱͬϰͬϮϬ ϯͬϭͬϮϬ E t
(spa)(mo-20-0013)(approval-document)(page-12)Page 12#
^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ DŝƐƐŽƵƌŝ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ͺͺͺͺͺ hƉ ƚŽ ƚŚĞ DĞĚŝĐĂƌĞ ƉĂLJŵĞŶƚƐ ĨŽƌ ĞƋƵŝǀĂůĞŶƚ ƐĞƌǀŝĐĞƐ͘ ͺͺͺͺͺ LJ ƚŚĞ ĨŽůůŽǁŝŶŐ ĨĂĐƚŽƌƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ WĂLJŵĞŶƚ ĨŽƌ ƐĞƌǀŝĐĞƐ ĚĞůŝǀĞƌĞĚ ǀŝĂ ƚĞůĞŚĞĂůƚŚ͗ ϯ͘ ͺͺͺͺͺ &Žƌ ƚŚĞ ĚƵƌĂƚŝŽŶ ŽĨ ƚŚĞ ĞŵĞƌŐĞŶĐLJ͕ ƚŚĞ ƐƚĂƚĞ ĂƵƚŚŽƌŝnjĞƐ ƉĂLJŵĞŶƚƐ ĨŽƌ ƚĞůĞŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŚĂƚ͗ Ă͘ ̴̴̴̴̴ ƌĞ ŶŽƚ ŽƚŚĞƌǁŝƐĞ ƉĂŝĚ ƵŶĚĞƌ ƚŚĞ DĞĚŝĐĂŝĚ ƐƚĂƚĞ ƉůĂŶ͖ ď͘ ͺͺͺͺͺ ŝĨĨĞƌ ĨƌŽŵ ƉĂLJŵĞŶƚƐ ĨŽƌ ƚŚĞ ƐĂŵĞ ƐĞƌǀŝĐĞƐ ǁŚĞŶ ƉƌŽǀŝĚĞĚ ĨĂĐĞ ƚŽ ĨĂĐĞ͖ Đ͘ ͺͺͺͺͺ ŝĨĨĞƌ ĨƌŽŵ ĐƵƌƌĞŶƚ ƐƚĂƚĞ ƉůĂŶ ƉƌŽǀŝƐŝŽŶƐ ŐŽǀĞƌŶŝŶŐ ƌĞŝŵďƵƌƐĞŵĞŶƚ ĨŽƌ ƚĞůĞŚĞĂůƚŚ͖ ĞƐĐƌŝďĞ ƚĞůĞŚĞĂůƚŚ ƉĂLJŵĞŶƚ ǀĂƌŝĂƚŝŽŶ͘ Ě͘ ͺͺͺͺͺ /ŶĐůƵĚĞ ƉĂLJŵĞŶƚ ĨŽƌ ĂŶĐŝůůĂƌLJ ĐŽƐƚƐ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ƚŚĞ ĚĞůŝǀĞƌLJ ŽĨ ĐŽǀĞƌĞĚ ƐĞƌǀŝĐĞƐ ǀŝĂ ƚĞůĞŚĞĂůƚŚ͕ ;ŝĨ ĂƉƉůŝĐĂďůĞͿ͕ ĂƐ ĨŽůůŽǁƐ͗ ŝ͘ ͺͺͺͺͺ ŶĐŝůůĂƌLJ ĐŽƐƚ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ƚŚĞ ŽƌŝŐŝŶĂƚŝŶŐ ƐŝƚĞ ĨŽƌ ƚĞůĞŚĞĂůƚŚ ŝƐ ŝŶĐŽƌƉŽƌĂƚĞĚ ŝŶƚŽ ĨĞĞͲĨŽƌͲƐĞƌǀŝĐĞ ƌĂƚĞƐ͘ ŝŝ͘ ͺͺͺͺͺ ŶĐŝůůĂƌLJ ĐŽƐƚ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ƚŚĞ ŽƌŝŐŝŶĂƚŝŶŐ ƐŝƚĞ ĨŽƌ ƚĞůĞŚĞĂůƚŚ ŝƐ ƐĞƉĂƌĂƚĞůLJ ƌĞŝŵďƵƌƐĞĚ ĂƐ ĂŶ ĂĚŵŝŶŝƐƚƌĂƚŝǀĞ ĐŽƐƚ ďLJ ƚŚĞ ƐƚĂƚĞ ǁŚĞŶ Ă DĞĚŝĐĂŝĚ ƐĞƌǀŝĐĞ ŝƐ ĚĞůŝǀĞƌĞĚ͘ KƚŚĞƌ͗ ϰ͘ ͺͺͺͺͺ KƚŚĞƌ ƉĂLJŵĞŶƚ ĐŚĂŶŐĞƐ͗ WůĞĂƐĞ ĚĞƐĐƌŝďĞ͘ ^ĞĐƚŝŽŶ & ʹ WŽƐƚͲ ůŝŐŝďŝůŝƚLJ dƌĞĂƚŵĞŶƚ ŽĨ /ŶĐŽŵĞ ϭ͘ ̴̴̴̴̴ dŚĞ ƐƚĂƚĞ ĞůĞĐƚƐ ƚŽ ŵŽĚŝĨLJ ƚŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ĨŽƌ ŝŶƐƚŝƚƵƚŝŽŶĂůŝnjĞĚ ŝŶĚŝǀŝĚƵĂůƐ͘ dŚĞ ďĂƐŝĐ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂůůŽǁĂŶĐĞ ŝƐ ĞƋƵĂů ƚŽ ŽŶĞ ŽĨ ƚŚĞ ĨŽůůŽǁŝŶŐ ĂŵŽƵŶƚƐ͗ Ă͘ ͺͺͺͺͺ dŚĞ ŝŶĚŝǀŝĚƵĂů͛Ɛ ƚŽƚĂů ŝŶĐŽŵĞ ď͘ ͺͺͺͺͺ ϯϬϬ ƉĞƌĐĞŶƚ ŽĨ ƚŚĞ ^^/ ĨĞĚĞƌĂů ďĞŶĞĨŝƚ ƌĂƚĞ ϮϬͲϬϬϭϯ ϱͬϰͬϮϬ ϯͬϭͬϮϬ E t
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^ƚĂƚĞͬdĞƌƌŝƚŽƌLJ͗ DŝƐƐŽƵƌŝ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ƉƉƌŽǀĂů ĂƚĞ͗ ͺͺͺͺͺͺͺͺͺͺ ^ƵƉĞƌƐĞĚĞƐ dE͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
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(spa)(mo-20-0016)(approval-document)Missouri Medicaid SPA MO-20-0016: Approval Document (approved July 30, 2020, effective April 1, 2020)#
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Table of Contents State/Territory Name: Missouri State Plan Amendment (SPA) #: 20-0016 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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DEPARTMENTOFHEALTH & HUMANSERVICES CentersforMedicare & MedicaidServices thStreet, Suite355 601East12 KansasCity, Missouri64106-2898 MedicaidandCHIPOperationsGroup August 3, 2020 Jennifer Tidball, Acting Director Missouri Department ofSocial Services Broadway StateOffice Building P.O. Box1527 Jefferson City, Missouri 65102-1527 Re: Missouri State PlanAmendment (SPA) 20-0016 DearMs. Tidball: OnJune29, 2020, theCenters forMedicare & Medicaid Services (CMS) received Missouri State Plan (SPA) No. 20-00016. ThisSPAwassubmitted inordertocome intocompliance withthe Home Health requirements through theCARES Act. Itwillallow advanced practice registered nursesandphysician assistants toorderhomehealth services andconduct facetofacevisitsin accordance with42CFR440.70(f). Wearepleased toinform youthatSPA20-0016wasapproved onJuly30, 2020, withaneffective dateofApril1, 2020, asrequested bythestate. Enclosed isacopyoftheCMS179summary form, aswellastheapproved pagesforincorporation intotheMissouri StatePlan. Ifyouhaveanyquestions regarding thismatter youmaycontact Deborah Read (816) 426-5925or bye-mailatDeborah.read@cms.hhs.gov. 8/3/2020 Sincerely, X JamesG. Scott, Director Division ofProgram Operations Signedby: JamesG. Scott -S Enclosures cc: ToddRichardson, SMD, MHD Glenda Kremer, MHD Marissa Crump, MHD Megan Buck, Program Branch Manager
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3.1-A Page12C 6.d. Otherpractitioners’ services continued Licensed Psychologist andSchoolPsychologist Anindependently enrolled Medicaid psychologist maybillonafee-for-service basisfor services foradultsandchildren inaccordance withinthepsychologist’sscopeof practice. School Psychologists certified undertheprogram standards oftheNational Association ofSchool Psychologists whoareemployed inadulyaccredited publicor charter schoolmayprovide services tostudents withinthescopeofemployment for suchschoolandwithinthescopeofhisorhereducation, training, andexperience. Anesthesiologist Assistant Anesthesiologist Assistant services arecovered byMissouri Medicaid whenperformed underthedirectsupervision ofananesthesiologist whoremains physically present and immediately available fordiagnosis andtreatment ofemergencies. AnAnesthesiologist Assistant mustbeenrolled asaprovider withMissouri Medicaid. Thespecific limitations maybefoundinthePhysician Provider Manual. 7.HomeHealth Services Homehealth services areprovided inaccordance with42CFR440.70andinclude nursing services; homehealth aideservices; physical therapy, occupational therapy, andspeech therapy services; andmedical supplies, equipment andappliances suitable foruseinanysettinginwhichnormallifeactivities takeplace. MOHealthNet willpayfor homehealthcareordered by, inaccordance with42CFR440.70(a)(2), aphysician, nursepractitioner, clinical nursespecialist, orphysician assistant, withinthescopeof practice authorized underStatelaw, aspartofawrittenPlanofCarecertifying theneed forhomehealthservices thattheordering practitioner reviews every60days. Aface- to-faceencounter, inaccordance with42CFR440.70(f) isrequired. Thestatewillcomply withhomeelectronic visitverification system requirements for homehealthservices byJanuary 1, 2023inaccordance withsection 12006ofthe21st Century CURES Act. StatePlanTN# 20-0016Effective Date April1, 2020 Supersedes TN# 18-0007 Approval Date __________
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3.1-A Page14 State Missouri 7.d. Physical therapy, occupational therapy, andspeechtherapy: Skilledtherapy services asdefinedunder42CFR440.70(b)(4) willbeconsidered reasonable and necessary fortreatment underthehomehealthprogramifthefollowing conditions aremet. A)TheServices: 1.Mustbeconsistent withthenatureandseverity oftheillness, andtheparticipant’s particular medical needs, and; 2.Mustbeconsidered, underaccepted standards ofmedical practice, tobespecific and effective treatment forthepatient’scondition, and; 3.Mustbeprovided withtheexpectation, basedontheassessment bytheordering practitioner oftheparticipant’srehabilitation potential, thattheparticipant’scondition will improve materially inareasonable andgenerally predictable periodoftime, and; 4.Arenecessary fortheestablishment ofasafeandeffective maintenance program, orfor teaching andtrainingacaregiver. 5.Mustbeprovidedinaccordance to42CFR440.110. 6.Mustbeprovided byahomehealthagencythatiscurrently licensed withtheMissouri Department ofHealthandSenior Services, isMedicare certified, andhasacurrentMO HealthNet provider agreement. B)Therapy services maybedelivered foronecertification period, ifservices areinitiatedwithin60 daysofonsetoftheconditionorwithin60daysfromdateofdischarge fromthehospital, ifthe participant washospitalized forthecondition. Priorauthorization tocontinue therapy servicesbeyond theinitialcertification periodmayberequested bythehomehealthprovider. Priorauthorization requests willbereviewed byMOHealthNet Division, andapproval ordenialofthecontinuation of services willbebasedontheservices’ continued adherence tothecriteriausedintheoriginal determination. 9.Clinicservices Clinicservices arepayabletoacliniconlyif 1)Theclinichassignedaparticipation agreement andhasbeensetupasaparticipating provider underoneofthefollowing provider types: Independent Clinic, PublicHealthDepartment Clinic, Planned Parenthood Clinic, Professional ClinicOptometry, Community MentalHealth Center. StatePlanTN# 20-0016 Effective Date April1, 2020 Supersedes TN# 18-0018Approval Date ___________
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Attachment4.19B Page3 StateMissouri EMERGENCYAMBULANCESERVICES Reimbursementforservicesismadeonafeeforservicebasis. Themaximumallowablefeeforaunitof servicehasbeendeterminedbyMOHealthNettobeareasonablefee, consistentwithefficiency, economy,andqualityofcare.Thestatepaymentforeachservicewillbethelowerof: 1.The actualchargefortheservices,or; 2.TheMedicaidmaximumallowableamountperunitofservice. Exceptasotherwisenotedintheplan, statedevelopedfeescheduleratesarethesameforboth governmentalandprivateprovidersofAmbulanceservices. The feescheduleratewassetasof July1,2019andiseffectiveforservicesprovidedonorafterthatdate. Allratesarepublishedat: https://dss.mo.gov/mhd/providers/pages/cptagree.htm.Tonavigatethesite,usersmustagreetothe licensuretermsandconditions,select5orC{andselect!ƒ HOMEHEALTHSERVICES Reimbursementforservicesismadeonafeeforservicebasis. Themaximumallowablefeeforaunitof servicehasbeendeterminedbyMOHealthNettobeareasonablefee, consistentwithefficiency, economy,andqualityofcare.Thestatepaymentforeachservicewillbethelowerof: 1.The actualchargefortheservices;or 2.TheMedicaidmaximumallowableamountperunitofservice. Exceptasotherwisenotedintheplan, statedevelopedfeescheduleratesarethesameforboth governmentalandprivateprovidersofhomehealthprogramservices( intermittentorparttimenursing services,homehealthaideservices,therapyservices,andmedicalsupplies).The feeschedule ratewassetasofJuly1,2019andiseffectiveforservicesprovidedonorafterthatdate. Allratesare publishedat:https://dss.mo.gov/mhd/providers/pages/cptagree.htm.Tonavigatethesite,usersmust agreetothelicensuretermsandconditions, select5orC{andselecth StatePlanTN# 200016EffectiveDate_April1,2020 SupersedesTN# 190016ApprovalDate_
(spa)(mo-20-0027)(approval-document)Missouri Medicaid SPA Mo-20-0027: Approval Document (approved March 3, 2021, effective October 1, 2020)#
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Table of Contents
State/Territory Name: Missouri State Plan Amendment (SPA) #: 20-0027 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Page
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106-2898
Medicaid & CHIP Operations Group
March 3, 2021
Jennifer Tidball Acting Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, Missouri 65102
Re: Missouri State Plan Amendment (SPA) 20-0027
Dear Ms. Tidball:
On December 3, 2020, the Centers for Medicare & Medicaid Services (CMS) received Missouri State Plan (SPA) No. 20-0027. This SPA was submitted to request technical changes to add information inadvertently omitted from Page 12c of Attachment 3.1-A during the submission of MO SPA 20-0016.
We are pleased to inform you that SPA 20-0027 was approved on March 3, 2021, with an effective date of October 1, 2020, as requested by the State. Enclosed is a copy of the CMS 179 summary form, as well as the approved pages for incorporation into the Missouri State Plan.
If you have any questions regarding this matter you may contact Deborah Read (816) 426-5925 or by e-mail at Deborah.read@cms.hhs.gov.
X
Enclosures
cc: Todd Richardson, SMD, MHD
Glenda Kremer, MHD
Sophia Hinojosa, Program Branch Manager
James G. Scott, Director Division of Program Operations Sincerely, Digitally signed by James G. Scott -S Date: 2021.03.03 17:00:03 -06'00'
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+BNFT(4DPUU %JSFDUPS %JWJTJPOPG1SPHSBN0QFSBUJPOT Digitally signed by James G. Scott -S Date: 2021.03.03 17:00:46 -06'00'
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3.1-A Page 12C 6.d. Other practitioners’ services continued Licensed Psychologist and SchoolPsychologist Licensed psychologists are able to furnish services within the scope of their practice as defined by State Law. School Psychologists, supervised by a licensed practitioner, are able to furnish services within the scope of their practice as defined by State Law. Anesthesiologist Assistant Anesthesiologist Assistant practitioners are supervised by a licensed Anesthesiologist. The licensed supervising practitioner is available for consultations and referrals of patients who need a higher level of care. The licensed supervising practitioner is practicing within their scope of practice as defined by State law, and assumes professional liability for the medical acts of the unlicensed practitioner. Acupuncturists Licensed Acupuncturists are able to furnish services within their scope of practice as defined by State Law. 6.d.(b) Other practitioners’ services Chiropractors Chiropractors' services include only services that are provided by a chiropractor who is licensed by the State and meets standards issued by the Secretary under § 405.232(b). Chiropractor services consist of treatment by means of manual manipulation of the spine that the chiropractor is legally authorized by the State to perform. 7. Home Health Services Home health services are provided in accordance with 42 CFR 440.70 and include nursing services; home health aide services; physical therapy, occupational therapy, and speech therapy services; and medical supplies, equipment and appliances suitable for use in any setting in which normal life activities take place. MO HealthNet will pay for home health care ordered by, in accordance with 42 CFR 440.70(a)(2), a physician, nurse practitioner, clinical nurse specialist, or physician assistant, within the scope of practice authorized under State law, as part of a written Plan of Care certifying the need for home health services that the ordering practitioner reviews every 60 days. A face- to-face encounter, in accordance with 42 CFR 440.70(f) is required. The state will comply with home electronic visit verification system requirements for home health services by January 1, 2023 in accordance with section 12006 of the 21st Century CURES Act. State Plan TN# 20-0027 Effective Date October 1, 2020 Supersedes TN# 20-0016 Approval Date 0DUFK
(spa)(mo-21-0029)(approval-document)Missouri Medicaid SPA MO-21-0029: Approval Document (approved December 17, 2021, effective July 1, 2021)#
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Table of Contents State/Territory Name: MO State Plan Amendment (SPA) #: 21-0029 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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(spa)(mo-21-0030)(approval-document)Missouri Medicaid SPA MO-21-0030: Approval Document (approved December 17, 2019, effective July 1, 2021)#
(spa)(mo-21-0030)(approval-document)(block-1)Missouri Medicaid SPA MO-21-0030: Approval Document (approved December 17, 2019, effective July 1, 2021)#
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(spa)(mo-21-0032)(approval-document)Missouri Medicaid SPA MO-21-0032: Approval Document (approved June 29, 2022, effective July 1, 2021)#
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Table of Contents State/Territory Name: MO State Plan Amendment (SPA) #: 21-0032 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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(spa)(mo-21-0037)(approval-document)Missouri Medicaid SPA MO-21-0037: Approval Document (approved December 17, 2021, effective October 1, 2021)#
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Table of Contents State/Territory Name: MO State Plan Amendment (SPA) #: 21-0037 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services
601 E. 12th St., Room 355
Kansas City, Missouri 64106
CMS
CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES
Medicaid and CHIP Operations Group
December 20, 2021
Todd Richardson
Director, MO HealthNet Division
State of Missouri, Department of Social Services 615 Howerton Court, PO Box 6500
Jefferson City, MO 65102
Re: Missouri State Plan Amendment (SPA) 21-0037 Dear Mr. Richardson:
The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (MO) 21-0037. This amendment proposes to provide authority to enroll the new Adult Expansion Group (AEG) into managed care and to provide services through the managed care program.
We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations 42 CFR § 435.733. This letter is to inform you that Missouri Medicaid SPA 21-0037 was approved on December 17, 2021, with an effective date of October 1, 2021.
If you have any questions, please contact Kia Carter-Anderson at 404-562-7431 or via email at kia.carter-anderson@cms.hhs.gov.
Sincerely.
Bill Brooks, Director Division of Managed Care Operations
ce: Kathryn Dinwiddie Tameka Whitney
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DEPARTMENT OF HEALTH AND HUMAN SERVICES. OAM ACPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES O40 No, 0930 0193
1, TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF 2 1 ..0 0 3 7 |Missouri STATE PLAN MATERIAL Some Ammer
FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL. SECURITY ACT (MEBICAID)
JO; REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES October 1, 2021 S. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN CD AMENDMENT TO BE CONSIDERED AS NEW PLAN CO) AmMcnowenr COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT Pudilc Law 111-148 (ACA); 42 CFR 433; 1905{y}(1) of tho Sociot Security Act; 1932(2) a. FFY 2! § 1,586,675,090 Social Security Act b. FFY.22 § 1,502,220, 120 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9, PAGE NUMBER OF THE SUPERSEBED PLAN SECTION Attachment 3.1-F, pages 1-923 Y Ny OR ATTACHMENT (l Apptieatts) ew
10, SUBJECT OF AMENDMENT
The purpose of this State Plan is to provide authority to enroll the new Adult Expansion Group (AEG) into Managed Care and to provide services through the Managed Care Program.
11. GOVERNOR'S REVIEW (Check One) =) V VERNOR'S OFFICE REPORTED NO CONMENT [ OTHER, AS SPECIFIED
OMMENTS OF GOVERNOR'S OFFICE ENCLOSED 1. NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
12, SIAM ereAC OP ROR SCA ALCIMAL 16. RETURN TO MO HealthNet Division “Bay “Moet . P.O. Box 6500 Ohen} —. Kou Lf | Jefferson City, Mo 65102 44. TITLE . Acting 15, DATE SUBMITTED 4 )21 /202) (P_ FOR REGIONAL OFFICE USE ONLY
17. DATE RECEIVED 18. DATE APPROVED.
September 21, 2021 December 17, 2021
PLAN APPROVED - ONE COPY ATTACHED 2.
19. EFFECTIVE DATE OF APPROVED MATERIAL 20, "nen NN ae
October 1, 2021 21. TYPEO NAME 22. ILE
Bill D. Brooks Director, Division of Managed Care Operations 23. REMARKS
FORM CMS-179 (07/82) Instructions on Back
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Citation Condition or Requirement
1932(a)(1)(A) A. Section 1932(a)(1)(A) of the Social Security Act.
The State ofMissourienrolls Medicaid beneficiaries on a mandatory basis into managed care entities (managed care organization [MCOs], primary care case managers [PCCMs ],and/or PCCM entities) in the absence ofsection 1115 or section 1915(b) waiver authority. This authority is granted under section 1932(a)(1)(A) ofthe Social Security Act (the Act). Under this authority, a state can amend its Medicaid state plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance with provisions ofsection 1902 ofthe Act on statewideness (42 CFR 431.50), freedomof choice (42 CFR 431.51) or comparability (42 CFR 440.230).
This authority may not be used to mandate enrollment in Prepaid Inpatient Health Plans (PIHPs), Prepaid Ambulatory Health Plans (PAHPs), norcan it be used to mandate the enrollment of Medicaid beneficiaries described in 42 CFR 438.50(d).
Where the state’s assurance is requested in this document for compliance with a particularrequirement of 42 CFR 438 et seq., the state shall place a check mark to affirm that it will be in compliance no laterthan theapplicable compliance date. All applicable assurances should be checked, even when the compliance date is in the future. Please see Appendix A of this document for compliance dates for various sections of 42 CFR 438.
1932(a)(1)(B)(i) B. Managed Care Delivery System 1932(a)(1)(B)(ii) 42 CFR 438.2 The State will contract with the entity(ies) below and reimburse themas noted 42 CFR 438.6 undereach entity type. 42 CFR 438.50(b)(1)-(2) 1. & MCO a. &XCapitation b. WThe stateassures thatall applicable requirements of 42 CFR 438.6, regarding special contract provisions related to payment, will be met.
2. O PCCM (individual practitioners) a. OO Case managementfee b. O Other(please explain below)
3. O PCCMentity a. OO Case managementfee b. CO Shared savings, incentive payments, and/or financial rewards(see 42 CFR 438.310(c)(2)) c. (© Other(please explain below)
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Citation Condition or Requirement
If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as in 42 CFR 438.2), in addition to PCCM services:
O Provision of intensive telephonic case management
Provision of face-to-face case management
Operation ofa nurse triage advice line
Developmentofenrollee care plans.
Execution ofcontracts with fee-for-service (FFS) providers in the FFS program
Oversightresponsibilities for the activities of FFS providers in the FFS program
Provision of payments to FFS providers on behalf ofthe State. Provision of enrollee outreach and education activities.
Operation ofa customer service call center.
Review of provider claims, utilization and/or practice pattems to conduct provider profiling and/or practice improvement. Implementation of quality improvementactivities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers. Coordination with behavioral health systems/providers. Coordination with long-termservices and supports systems /providers. Other (please describe):
O OO00 O fn000
oo0a
42 CFR 438.50(b)(4) C. Public Process.
Describe the public process including tribal consultation, ifapplicable, utilized for both the design of the managed care programanzd its initial implementation. In addition, describe what methods the state will use to ensure ongoing public involvement oncethe state plan managed care programhas been implemented. (Example: public meeting, advisory groups.)
If the programwill include long termservices and supports (LTSS), please indicate how the views of stakeholders have been, and will continue to be, solicitedand addressed during the design, implementation, and oversight ofthe program, including plans fora member advisory committee (42 CFR 438.70 and 438.110)
Response: Missouri’s MO HealthNet Managed Care programhas been in existence since 1995, and has been statewide for pregnant women, children and custodial adults since 2017. The State believes that one ofthe keys to a successful program include the involvement and input of stakeholders to informhealth care policy and service delivery. Examples of forums, workgroups, meetings and other means of engaging our stakeholder partners are:
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e The Member Forumwhich is inclusive of participants in both the managed care and fee-for-service programs.
¢ Periodic meetings with Cover Missouri, a group working to assist Missourians in obtaining health insurance.
e Frequent meetings and interactions with Advocates for Family Health, an ombudsmen service regarding ways to help individuals access care more easily and ways to coordinate care with other state agencies.
e The Quality Assuranceand Improvement Advisory Group (QA &I) which is open to the public and includes all ofthe Managed Care Organizations, state staff, other state agency staff, Advocates for Family Health, and, other consumer advocates and interested parties.
e Periodic meetings with provider groups suchas the Missouri Primary Care Association, Missouri Dental Association, Missouri Hospital Association, Quarterly Hospital Meetings, Dental Advis ory Committee, Dental Task Force, Durable Medical Equipment Provider Meeting; the Drug Utilization Review Board, as well as individual providers.
e Collaboration and regular meetings with the Department of Health and Senior Services, the Department of Mental Health, andthe Department of Elementary and Secondary Education, as wellas with other divisions within the Department of Social Services.
e Special workgroups formed to enhance the quality of our programs and services including the Encounter Data Workgroup, the Quality Data Validation Workgroup, and, the Follow-up A fter Hospitalization for Mental Illness group.
¢ State webpage with information for participants, contracted health plans, providers, and, the public.
e Public hearings and commentperiods for public input when policy is changed or new policy is created.
e Publication of provider bulletins on the State website and the opportunity for anyoneto receive programupdates through email blasts.
The State’s expansion of Medicaid to the Adult Expansion Group (AEG) is the result ofa voter ballot initiative amending the State Constitution. Public interest groups worked together for over two years to place the initiative on the ballot in August 2020. Since that time, the State useda “Teamof Teams” approach to coordinate all state entities necessary to make decisions and operationalize the implementation ofthe program.
Missouri does not have federally recognized Native A merican tribes therefore, tribal consultations were notheld. Missouri does not offer Long Term Services
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State and Supports (LTSS) in the Managed Care Program. D. State Assurances and Compliance with the Statute and Regulations. If applicable to the stateplan, placea check mark to affirm that compliance with the following statutes and regulations will be met. 1932(a)(1)(A)(i)(D 1. & Thestateassures thatall of the applicable requirementsof 1903(m) section 1903(m) ofthe Act, forMCOs and MCO contracts will bemet. TN No. 21-0037 Supersedes Approval Date_12/17/2021 Effective Date: 10/01/2021
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State
Citation Condition or Requirement
42 CFR 438.50(c)(1)
1932(a)(1)(A)(i)(D 2. Thestateassures thatallthe applicable requirements of section 1905(t)
1905(t) of the Act for PCCMs and PCCM contracts (including for PCCM entities ) will be met.
42 CFR 438.50(c)(2)
1902(a)(23)(A)
1932(a)(1)(A) 3. & Thestateassures thatall the applicable requirements ofsection 1932
42 CFR 438.50(c)(3) (including subpart(a)(1)(A)) ofthe Act, forthe state's option to limit freedom of choice by requiring beneficiaries to receive their benefits through managed care entities will be met.
1932(a)(1)(A) 4. & Thestateassures thatallthe applicable requirements of 42 CFR 431.51
42 CFR 431.51 regarding freedomof choice for family planning services and supplies as
1905(a)(4)(C) defined in section 1905(a)(4)(C) will be met.
42 CFR 438.10(g)(2)(vii)
1932(a)(1)(A) 3: The state assures that it appropriately identifies individuals in the mandatory exempt groups identified in 1932(a)(1)(A)(i).
1932(a)(1)(A) 6. & Thestate assures thatallapplicable managed care requirements of
42 CFR 438 42 CFR Part 438 for MCOs, PCCMs, and PCCM entities will be met.
1903(m)
1932(a)(1)(A) 7. The stateassures thatall applicable requirements of 42 CFR 438.4, 438.5, 438.7, 438.8, and 438.74 for payments under any risk contracts will be met.
42 CFR 438.4
42 CFR 438.5
42 CFR 438.7
42 CFR 438.8
42 CFR 438.74
42 CFR 438.50(c)(6)
1932(a)(1)(A) 8. Thestateassures thatall applicable requirements of 42 CFR 447.362 for
42 CFR 447.362 payments under any non-risk contracts will be met.
42 CFR 438.50(c)(6)
45 CFR 75.326 9. & Thestateassures thatall applicable requirements of 45 CFR 75.326 for procurement of contracts will be met.
42 CFR 438.66 10. Assurances regarding state monitoring requirements:
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Citation Condition or Requirement
& The state assures thatall applicable requirements of 42 CFR 438.66(a), (b), and (c), regarding a monitoring systemand using data to improve the performance ofits managed care program, will be met.
&) The state assures thatall applicable requirements of 42 CFR 438.66(d), regarding readiness assessment, will be met.
&X] The state assures thatall applicable requirements of 42 CFR 438.66(e), regarding reporting to CMS aboutthe managed care program, will be met.
1932(a)(1)(A) E. Populations and Geographic Area. 1932(a)(2) 1. Included Populations. Please check which eligibility groups are included, if
they are enrolled on a Mandatory (M) or Voluntary (V) basis (as defined in 42 CFR 438.54(b)) or Excluded (BE), and the geographic scope ofenrollment. Under the Geographic Area column, please indicate whether the nature of the population’s enrollment is on a statewide basis, or if on less than a statewide basis, please list the applicable counties/regions. Aso, iftype of enrollment varies by geographic area (for example, mandatory in some areas and voluntary in otherareas), please note specifics in the Geographic Area column. Under the Notes column, please note any additional relevant details about the population or enrollment.
A. Mandatory HligibilityGroups (HigibilityGroups to which a state must provide Medicaid coverage) 1. Family/Adult
. Parents and Other Caretaker Relatives |§435.110 2. Pregnant Women §435.116
Children Under Age 19 (Inclusiveof |§435.118 Deemed Newborns under §435.117)
4. Former Foster Care Youth (uptoage —_{§435.150 26)
5. Adult Group (Non-pregnant §435.119 individuals age 19-64 not eligible for i Statewide Medicare with income no more than 133% FPL)
6. Transitional Medical Assistance 1902(a)(52), (Includes adults and children, if not 1902(e)(1), 1925, eligible under §435.116, §435.118,or Jand 1931(c)(2) of} §435.119) ISSA
7. Extended Medicaid Due to Spousal IS435.115 Support Collections
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Citation Condition or Requirement
2. _Aged/Blind/Disabled Individuals
8. Individuals Receiving SSI age 19 and over |§435.120 only (See E.2. below regarding age <19)
9. Aged and Disabled Individuals in 209(b) [§435.121 States
10. Individuals Who Would be Eligible for 8435.135 SSI/SSP_ but for OASDI COLA Increase since April, 1977
11. Disabled Widows and Widowers 18435.137 Ineligible for SSI due to an increase of OASDI 12. Disabled Widows and Widowers 435.138 Ineligible for SSI due to Early Receipt of Social Security 13. Working Disabled under 1619(b) 1619(b), 1902(a)(10)(A\in IT), and 1905(q) 0 ISSA 14. Disabled Adult Children 1634(c) of SSA
B. Optional Hligibility Groups 1. _Family/Adult
Optional Parents and Other Caretaker §435.220 Relatives . Optional Targeted Low-Income Children _ |§435.229 3. Independent Foster Care Adolescents IS435.226 Under Age 21 4. Individuals Under Age 65 with Income $435.218 Over 133%
5. Optional Reasonable Classifications of $435.222 Children Under Age 21
6. Individuals Electing COBRA 1902(a)(10)(F) of} Continuation Coverage ISSA
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Citation Condition or Requirement
2. Aged/Blind/Disabled Individuals
Aged, Blind or Disabled Individuals §435.210 and Eligible for but Not Receiving Cash 1§435.230
8. Individuals eligible for Cash except for S435.211 Institutionalized Status
9. Individuals Receiving Home and I8435.217 Community-Based Waiver Services Under Institutional Rules
10. Optional State Supplement Recipients - I$435.232 1634 andSSI Criteria States— with 1616 Agreements
11. Optional State Supplemental Recipients- §435.234 209(b) States and SSI criteria States without_1616 Agreements
12. Institutionalized Individuals Eligible under |§435.236 a Special Income Level
13. Individuals Participating in a PACE 1934 of the SSA Program under Institutional Rules 14. Individuals Receiving Hospice Care 1902(a)(10)(A)(ii] VII) and 1905(0) lof the SSA 15. Poverty Level Aged or Disabled 1902(a)(10)(A)(ii] X) and 1902(m)(1) of the ISSA 16. Work Incentive Group 1902(a)(10)(A)(iil XIID) of the SSA 17. Ticket to Work Basic Group 1902(a)(10)(A)(iil XV) of the SSA 18. Ticket to Work Medically Improved 1902(a)(10)(A)(ii Group XVI) of the SSA 19. Family Opportunity Act Children with 1902(a)(10)(A)(iil Disabilities XIX) of the SSA
20. Individuals Eligible for State Plan Home I$435.219 and Community-Based Services
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State Citation Condition or Requirement 3.__ Partial Benefits 21. Family Planning Services I$435.214 22. Individuals with Tuberculosis 8435.215
23. Individuals Needing Treatment for Breast |§435.213 or Cervical Cancer (under age 65)
C._ Medically Nee
Medically Needy Pregnant Women 35.301(b)(1)(i) ind (iv)
Medically Needy Children under Age 18 [§435.301(b)(1)(ii Medically Needy Children Age 18 through |§435.308 20
4. Medically Needy Parents and Other S435.310 Caretaker Relatives
5. Medically Needy Aged I$435.320
6. Medically Needy Blind §435.322
7. Medically Needy Disabled I$435.324
8. Medically Needy Aged, Blind and IS435.330 Disabled in 209(b) States
2. Voluntary Only or Excluded Populations. Under this managed care authority, some populations cannot be subject to mandatory enrollment in an MCO, PCCM, or PCCM entity (per42 CFR 438.50(d)). Some such populations are Eligibility Groups separate fromthose listed above in E.1., while others (suchas American Indians/Alaskan Natives) can be part of multiple Eligibility Groups identified in El. above.
Please indicate if any of the following populations are excluded from the program, or have only voluntary enrollment (even ifthey are part ofan eligibility group listedabovein E.1. as having mandatory enrollment):
Medicare Savings Program— Qualified | 1902(a)(10)(E), 1905(p), Medicare Beneficiaries, Qualified 1905(s) of the SSA Disabled Working Individuals, Specified Low Income Medicare Beneficiaries, and/or Qualifying Individuals
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Citation Condition or Requirement
“Dual Higibles” not described under Medicare Savings Program - Medicaid beneficiaries enrolled in an eligibility group other than one of the Medicare Savings Program groups who are also eligible for Medicare
American Indian/Alaskan Native— §438.14 Medicaid beneficiaries who are American Indians or Alaskan Natives and members of federally recognized tribes
Children Receiving SSI who are Under | §435.120 Age 19- Children under 19 years of age who are eligible for SSI_under title XVI Qualified Disabled Children Under §435.225
Age 19- Certain children under 19 living | 1902(e)(3) of the SSA at home, who are disabled and would be eligible if they were living in a medical institution.
Title IV-E Children - Children receiving | $435.145 foster care, adoption assistance, or kinship guardianship assistance under title IV-E *
Non-Title IV-E Adoption Assistance §435.227 Under Age 21*
Children with Special Health Care Needs - Receiving services through a family-centered, community-based, coordinated care system that receives grant funds under section 501(a)(1)(D) of Title V, and is defined by the State in terms of either program participation or special health care needs.
* = Note — Individuals in these two Eligibility Groups who are age 19 and 20 can have mandatory enrollment in managed care, while those under age 19 cannot have mandatory enrollment. Use the Notes column to indicate if you plan to mandatorily enroll 19 and 20 year olds in these Eligibility
Groups.
3. (Optional) Other Exceptions. The following populations (which canbe part of various Eligibility Groups) can be subject to mandatory enrollment in managed
care, but states may elect to make exceptions for these or other individuals. Please indicate ifany of the following populations are excluded fromthe program, or have only voluntary enrollment (even if they are part ofan eligibility group listedabovein E.1. as having mandatory enrollment):
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Citation Condition or Requirement
Other Insurance—Medicaid beneficiaries who have other health insurance
Reside in Nursing Facility or IC F/IID-- Medicaid beneficiaries who reside in Nursing Facilities (NF) or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID).
Enrolledin Another Managed Care Program- -Medicaid beneficiaries who are enrolled in another Medicaid managed care program
Higibility Less Than 3 Months--Medicaid beneficiaries who would have less than three months of Medicaid eligibility remaining upon enrollment into the program
Participate in HCBS Waiver--Medicaid beneficiaries who participate ina Home and Community Based Waiver (HCBS, also referred to as a 1915(c) waiver).
Retroactive Higibility—Medicaid beneficiaries for the period of retroactive eligibility.
Other (Please define):
1932(a)(4)
42 CFR 438.54
Enrollment Process.
Based on whether mandatory and/or voluntary enrollment are applicable to your program (see E. Populations and Geographic Area and definitions in 42 CFR 438.54(b)), please complete the below:
1. Forvoluntary enrollment: (see 42 CFR 438.54(c))
a.
Please describe how thestate fulfills its obligations to provide information as specicifed in 42 CFR 438.10(c)(4), 42 CFR 438.10(e) and 42 CFR 438.54(c)(3).
State with voluntary enrollment musthave an enrollment choice period or passive enrollment. Please indicate which will apply to the managed care program: O If applicable, please check here to indicate that the state provides an enrollment choice period, as described in 42 CFR 438.54(c)(1)(i) and 42 CFR 438.54(c)(2)(i), during which individuals who are subjectto voluntary enrollment may make an active choice to enrollin the managed care program, or will otherwise continue to receive covered services through the fee-for-service delivery system.
i. Please indicate the length oftheenrollment choiceperiod:
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Citation Condition or Requirement
c. OTIf applicable, please check here to indicate that the stateuses a passive enrollment process, as described in 42 CFR 438.54(c)(1)(ii) and 438.54(c)(2)(ii), for individuals whoare subjectto voluntaryenrollment.
i. Ifso, please describe thealgorithmused for passive enrollment and how the algorithmand the state’s provision ofinformation meets all ofthe requirements of 42 CFR
438.54(c)(4),(5),(6),(7), and (8). ii. Please indicate how long the enrollee will have to disenroll from the plan and return to the fee-for-service delivery system:
2. Formandatory enrollment: (see 42 CFR 438.54(d)) a. Please describe how the state fulfills its obligations to provide information
as specified in 42 CFR 438.10(c)(4), 42 CFR 438.10(e) and 42 CFR 438.54(d)(3).
Response: The stateuses an enrollment broker that provides each potential enrollee an enrollment packetthat contains an informational brochure onthe MO HealthNet Managed Care Programincluding its benefits and use, the MCOs available, and information on how to access the PCP listing. A toll free enrollment help line is available 7 a.m. to 6 p.m., Monday through Friday except for holidays. Trained Enrollment Counselors educate enrollees and potential enrollees who call the MO HealthNet Managed Care Enrollment Helpline on the MO HealthNet Managed Care Programbenefits and use.
The State requires the enrollment broker to provide ongoing outreach for the purpose of providing an understanding of MO HealthNet Managed Care, how it works, its benefits, and to assist the MO HealthNet Managed Care enrollee to make informed decisions. Theenrollment broker develops and provides outreach materials to MO HealthNet Managed Care enrollees throughout the state. Ifrequired by the State, the enrollment broker conducts community outreach group presentations. The enrollment broker, through the enrollment packet, notifies all potential enrollees that oral translation services are available by calling the MO HealthNet Managed Care Enrollment Helpline. The enrollment broker utilizes TeleInterpreters powered by Language Line for oral translation services. The enrollment broker also has three bi-lingual, Spanish speaking enrollment counselors. Relay Missouri is utilized for the hearing impaired. Relay Missouriis a service that provides full telephone accessibility to people who are deaf, hard ofhearing, deaf-
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State blind, and speech disabled. These services are available 24 hours a day, seven days a week and there is no charge for anyone touse.
b. If applicable, please check here to indicate that thestate provides an enrollment choice period, as described in 42 CFR 438.54(d)(2)(i), during which individuals who are subject to mandatory enrollment may make an active choice to selecta managed care plan, or will otherwise be enrolled in a plan selected by the State’s default enrollment process.
i. Please indicate the length ofthe enrollment choice period:
Response: The State auto-assigns enrollees into a health plan on the day they are
found eligible for MO HealthNet. The algorithmis described below. Ifan
enrollee wishes to change their health plan, they may do so within 90 days for any reason, then at any time forjust cause reasons.
Ci If applicable, please check here to indicate that the state uses a default enrollment process, as described in 42 CFR 438.54(d)(5), for individuals who are subject to mandatory enrollment.
i. Ifso, please describe thealgorithmused for default enrollment and how it meets all ofthe requirements of 42 CFR 438.54(d)(4), (5), (7), and (8).
Response: The auto-assignmentalgorithmas signs enrollees as follows:
a) Ifthe MO HealthNet Managed Care enrollee is enrolled with a MCO, the MO HealthNet Managed Care enrollee shall be assigned to that MCO. If not, the next step in the algorithmwill be followed.
b) Ifthe MO HealthNet Managed Care enrollee is included in a MO HealthNet eligibility case where another enrollee is enrolled with a MCO, the MO HealthNet Managed Care enrollee shall be assigned to that MCO. If not, the MO HealthNet Managed Care enrollee will be assigned randomly as outlined in the remainder of the section.
c) IfaMCO has fifty-five percent (55%) ofthe regional membership or greater, regional auto-assignment into the MCO will be limited to enrollees meeting the algorithmcriteria for only items (a) and (b) above.
d) Ifone MCOhas less than twenty percent (20%) of the regional membership or 25,000 members, whichever is greater, that MCO will receive one hundred percent (100%) of the auto-assigned membership following the application ofthe algorithmcriteria for items (a) and (b) above.
e) Ifmultiple MCOs have enrollment below twenty percent (20%) of the regional membership or 25,000 members, whichever is greater, 100% of the auto-assignments, following the application of the algorithmcriteria for items (a) and (b) above, will be shared equally among the MCOs with less than twenty percent (20%) of the regional members hip or 25,000 members, whichever is greater. The MCOwith the highest evaluation score (determined by the
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State of Missouri) will receive the first member.
f) Ifall MCOs have at leasttwenty percent (20%) or 25,000 members, whichever is greater, and less than fifty-five percent (55%) of the membership within each region, the MCOs shall equally share in the allocation fromthe auto-assignment process following the application ofthe algorithmcriteria for items (a) and (b) above.
g) Theenrollment percentage by MCOandby region will be calculated ona monthly basis. Ifthe enrollment percentage by MCO and by region necessitates a change in the auto-assignment algorithm, the change will be implemented on the first business day ofthe following month and will remain in effect until the enrollment percentages trigger another change in the application of the auto-assignmentalgorithm. Actual enrollment will be determined based on each MCO’s enrollment market share during the last week ofeach month and reported to each MCO.
d. Of applicable, please check here to indicate that the state uses a passive enrollment process, as described in 42 CFR 438.54(d)(2), for individuals who are subject to mandatory enrollment.
i. Ifso, please describe thealgorithmused for passive enrollment and how it meets all ofthe requirements of 42 CFR 438.54(d)(4), (6), (7), and (8).
1932(a)(4) 3. State assurances onthe enrollment process. 42 CFR 438.54 Place a check mark to affirm the state has met all ofthe applicable requirements
of choice, enrollment, and re-enrollment. 42 CFR 438.52 a.& The stateassures that, per the choice requirements in 42 CFR 438.52:
, i. Medicaid beneficiaries with mandatory enrollment in an MCO Citation will have a choice of a least two MCOs unless the area is we considered ruralas defined in 42 CFR 438.52(b)(3); Condition or
Requirement ii. Medicaid beneficiaries with mandatory enrollment in a primary care case managements ystem will have a choice ofat least two
primary care case managers employed by or contracted with the State;
iii. Medicaid beneficiaries with mandatory enrollment in a PCCM entity may be limited to a single PCCM entity and willhave a choice ofat least two PCCMs employed by orcontracted with the PCCM entity.
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b. O The state planprogramapplies the rural exception to choice requirements of 42 CFR 438.52(a) for MCOs in accordance with 42 CFR 438.52(b). Please list the impacted rural counties:
XIThis provision is not applicable to this 1932 State Plan Amendment.
c. & Thestate applies the automatic reenrollment provision in accordance with 42 CFR 438.56(g) if the recipient is disenrolled solely because he orshe loses Medicaid eligibility fora period of 2 months orless.
O This provision is notapplicable to this 1932 State Plan Amendment.
42 CFR 438.71 d. & The stateassures thatall applicable requirements of 42 CFR 438.71 regarding developing and implementing a beneficiary support s ystemthat provides support to beneficiaries both prior to and after MCO, PCCM, or PCCM entity enrollment will be met.
1932(a)(4) G.__ Disenrollment. 42 CFR 438.56 1. The statewillX!/ will not limit disenrollment for managed care.
2. The disenrollment limitation will apply for12 months(up to 12 months).
3, The state assures that beneficiary requests for disenrollment (with and without cause) will be permitted in accordance with 42 CFR 438.56.
4. Describe the state's process for notifying the Medicaid beneficiaries of theirright to disenroll without cause during the 90 days following the date of their initial enrollment into the MCO, PCCM, or PCCM entity. (Examples: state generated correspondence, enrollment packets, etc.)
Response: Beneficiaries are informed oftheir right to disenroll without cause through theservices provided by the enrollment broker; in enrollment materials published onthe state’s website and in the enrollment packet; and, in the member handbook provided by the beneficiary’s health plan.
5. Describe any additional circumstances of “cause” for disenrollment (ifany).
e The enrollee requests a transfer during open enrollment.
e¢ The enrollee requests a transfer during the first 90 days enrolled in the MCO. Trans fer is the resolution to a grievance or appeal. The PCP orspecialist with whomthe enrollee has an established patient/provider relationship does not participate in the MCO they are currently enrolled in but does participate in another MCO.
e The enrollee is pregnantandher PCP or OB/GYN does not participate in the MCO but does participate in another MCO.
e¢ The enrollee is anewborn andthe PCP or pediatrician selected by the mother does not participate in the MCO but does in another MCO. Trans fer to another MCO is necessary to ensure continuity of care. An act ofcultural insensitivity that negatively impacts the enrollee’s ability
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to obtain care and cannot be resolved by the MCO.
e The enrollee had an address change and did not receive an enrollment packet. As a result, the enrollee was randomly assigned to the MCO.
e Information on the PCP listing was incorrect. The MCOchosenby the enrollee was based onthe information given onthe listing.
e Aspecialhealth care needs enrollee (Title V, SSI and foster care) requests a different MCO with the approval ofthe State.
¢ Children in State custody or foster care placementare allowed automatic and unlimited changes in MCO. They may change MCOs as oftenas their foster care placement changes necessitate. Foster parents normally have the decision-making responsibility for choosing which MCO will serve the foster child residing with them. However, there will be situations where the social service worker or the courts will select the MCO for the child in State custody or foster care placement.
e Any adoption subsidy individual may choose notto enroll or voluntarily disenrollat any time.
e Any individual receiving SSI or who meets the medical definition for SSI benefits may choosenotto enroll or voluntarily disenroll at any time.
e — Trans ferto another health plan is necessary to correct an error made by the enrollment broker orthe state agency during the previous assignment process.
e May also request transfer in order forall family members to be enrolled with the same health plan.
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State Citation Condition or Requirement H. Information Requirements for Beneficiaries. 1932(a)(5)(c) XiThe stateassures thatits state plan programis in compliance with 42 CFR 42 CFR 438.50 438.10 for information requirements specific to MCOs, PCCMs, and PCCM entity
42 CFR 438.10
1932(a)(5)(D)(b) 1903(m) 1905(t)(3)
programs operated under section 1932(a)(1)(A)(i) state plan amendments.
List all benefits for which the MCO is responsibk.
Complete the chart below to indicate every State Plan-A pproved services that will be delivered by the MCO, and where each of those services is described in the state’s Medicaid State Plan. For “other practitioner services”, list each provider type separately. For rehabilitative services, habilitative services, EPSDT services and 1915(i), (j) and (k) services list each programs eparately by its own list of services. Addadditional rows as necessary.
In the first column ofthe chart below, enter the name ofeach State Plan-Approved service delivered by the MCO. In the second — fourth column ofthe chart, entera State Plan citation providing the Attachment number, Page number, and Item number, respectively.
State Plan-A pproved Service Delivered by the MCO
Medicaid State Plan Citation
lo Outpatient Hospital Services
lo Family Planning Services lo Physician Services
lo Podiatrist Services
lo Nurse Practitioners/Clinical Nurse Specialist
lo Physician Assistant lo Assistant Physician
lo Chiropractor
lo Anesthesiologist Assistant
lo Clinic Services
lo Dental Services
lo Hospice
lo Non-Emergency Medical Transportation NEMT)
Attachment# Page # Item# Ex. Physical Therapy 3.1-A 4 I1.a Ambulatory Patient Services IABPS AEG 2-6 1
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State: [Emergency Services IABP5 AEG 7-8 lo Emergency Medical Technicians lo Paramedics lo Transportation lo Outpatient Hospital Services Hospitalization IABPS AEG 9 lo Inpatient Hospital lo Physician Services [Maternity and Newborn Care IABPS5 AEG 10 lo Nurse Mid-Wife Services lo Family Nurse/Pediatric Nurse Practitioner lo Free Standing Birth Center [Mental Health and Substance Use Disorder |ABPS AEG 12-14 Services Including Behavioral Health Treatment lo Behavioral Health Services lo Community Psychiatric Rehabilitation lo Comprehensive Substance Treatment & Rehab (CSTAR) lo Certified Community Behavioral Health (Organization lo Inpatient Psychiatric Facility Services under 22) lo Inpatient Hospital — Detoxification Prescription Drugs IABPS AEG 15 Rehabilitative and Habilitative Services and IABPS AEG 16-18 Devices lo Inpatient Hospital — Rehabilitative lo Skilled Nursing Facility Services lo Durable Medical Equipment/Prosthetics lo Complementary Med and Alternatives to Pain Management lo Outpatient Hospital Cardiac Rehabilitation lo Home Health lo Habilitative Services lo Personal Care Services Laboratory Services IABPS AEG 19 lo Laboratory and X-Ray Services Preventive and Wellness Services and Chronic IABPS AEG 20 [Disease Management lo Preventative Care/Screening/Immunization lo Diabetes Prevention Program Services TN No. 21-0037 Supersedes Approval Date_12/17/2021 Effective Date: 10/01/2021
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State:
Pediatric Services Including Oral and Vision Care |ABP5 AEG 21 9 lo Medicaid State Plan EPSDT Benefits
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Citation Condition or Requirement
1932(a)(5\(D)(b\(4) J. The state assures that each MCO has established an internal grievance and appeal system for
enrollees. 42 CFR 438.228 1932(a)(5)(D)(b)(5) K. Services, including capacity, network adequacy, coordination, and continuity. 42 CFR 438.62 42 CFR 438.68 42 CFR 438.206 42 CFR 438.207 42 CFR 438.208 The state assures that all applicable requirements of 42 CFR 438.62, regarding continued service to enrollees, will be met. &The state assures thatall applicable requirements of 42 CFR 438.68, regarding network adequacy standards, will be met. &The state assures thatall applicable requirements of 42 CFR 438.206, regarding availability of services, will be met. &The state assures thatall applicable requirements of 42 CFR 438.207, regarding assurances of adequate capacity and services, will be met. W&The state assures thatall applicable requirements of 42 CFR 438.208, regarding coordination and continuity of care, will be met. 1932(c)(1)(A) L. &Thestateassures thatall applicable requirements of 42 CFR 438.330 and 438.340, regarding a quality assessment and performance improvement programand State quality strategy, will be met. 42 CFR 438.330 42 CFR 438.340 1932(c)(2)(A) M. Q&Thestateassures thatall applicable requirements of 42 CFR 438.350, 438.354, and 438.364 regarding an annual external independent review conducted bya qualified independent entity, will be met. 42 CFR 438.350 42 CFR 438.354 42 CFR 438.364
1932 (a)(1)(A (ii) N. Selective Contracting Undera 1932 State Plan Option.
To respond to items #1 and #2, place a check mark. The third itemrequires a brief narrative.
1. The state will X will not CO intentionally limit the number of entities it contracts undera 1932 state plan option.
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State:
Citation Condition or Requirement
2. & The state assures that if it limits the number of contracting entities, this limitation will not substantially impair beneficiary access to services.
3. Describe thecriteria thes tate uses to limit the number of entities it contractsunder a 1932 state plan option. (Example: a limited number of providers and/or enrollees.)
Response: Thestate contracts with three Managed Care Organizations in order to provide sufficient access and coverage throughout the state. Limiting the number of contracted MCOs helps to provide a cohesive program for the number of participants in the program.
4. © The selective contracting provision in not applicable to this stateplan.
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Citation
Condition or Requirement
Appendix A: Compliance Dates (from Supplementary Information in 81 FR 27497, published 5/6/2016)
States must comply with all provisions in effect as of the issuance of this preprint. Additionally, the following
compliance dates apply:
Compliance Dates
Sections
Forrating periods for Medicaid managed care contracts beginning before July 1, 2017, States willnot be held out of compliance with the changes adopted in the following sections so long as they comply with the corresponding standard(s) codified in 42 CFR part 438 contained in 42 CFR parts 430 to 481, edition revisedas of October 1,2015. States must comply with these requirements no later than the rating period for Medicaid managed care contracts starting on or after July 1, 2017.
§§ 438.3(h), 438.3(m), 438.3(q) through(u), 438.4(b)(7), 438.4(b)(8), 438.5(b) through (f), 438.6(b)(3), 438.6(c) and (d),438.7(b), 438.7(c)(1) and (2), 438.8, 438.9, 438.10, 438.14, 438.56(d)(2)(iv), 438.66(a) through (d), 438.70, 438.74, 438.110, 438.208, 438.210, 438.230, 438.242, 438.330, 438.332, 438.400, 438.402, 438.404, 438.406, 438.408, 438.410, 438.414, 438.416, 438.420, 438.424, 438.602(a), 438.602(c) through (h), 438.604, 438.606, 438.608(a), and 438.608(c) and (d)
Forrating periods for Medicaid managed care contracts beginning before July 1, 2018, states willnot be held out of compliance with the changes adopted in the following sections so long as they comply with the corresponding standard(s) codified in 42 CFR part 438 contained in the 42 CFR parts 430 to 481, edition revisedas of October 1, 2015. States must comply with these requirements no later than the rating period for Medicaid managed care contracts starting on or after July 1,2018.
§§ 438.4(b)(3), 438.4(b)(4), 438.7(c)(3), 438.62, 438.68, 438.71, 438.206, 438.207, 438.602(b), 438.608(b), and 438.818
States must be in compliance with the requirements at § 438.4(b)(9) no later than the rating period for Medicaid managed care contracts starting on or after July 1, 2019.
§ 438.4(b)(9)
States must be in compliance with the requirements at
§ 438.66(e) no later than the rating period for Medicaid managed care contracts starting on or after the date of the publication of CMS guidance.
§ 438.66(€)
States must be in compliance with § 438.334 no later than 3 years from the date of a final notice published in the Federal Register.
§ 438.334
Until July 1, 2018, states willnot be held out of compliance with the changes adopted in the following sections so long as they comply with the corresponding standard(s) codified in 42
§§ 438.340, 438.350, 438.354, 438.356, 438.358, 438.360, 438.362, and 438.364
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State Citation Condition or Requirement Compliance Dates Sections
CFR part 438 contained in the 42 CFR parts 430 to 481, edition revised as of October 1, 2015.
States mustbegin conducting the EQR-related activity described | § 438.358(b)(1)(iv) in § 438.358(b)(1)(iv) (relating to the mandatory EQR-related activity of validation ofnetwork adequacy) no later than one year from the issuance of the associated EQR protocol.
States may begin conducting the EQR-related activity described | § 438.358(c)(6) in § 438.358(c)(6) (relating to the optional EQR-related activity of plan rating) no earlier than the issuance of the associated EOR protocol.
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- 0933. The time required to complete this information collection is estimated to average 10 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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Table of Contents
State/Territory Name: Missouri State Plan Amendment (SPA) #: 22-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 September , 2022 Robert Knodell Acting Director Missouri Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, Missouri 65102 Re: Missouri State Plan Amendment (SPA) 22-0012 Dear Mr. Knodell: On June 6, 2022, the Centers for Medicare & Medicaid Services (CMS) received Missouri State Plan (SPA) No. 22-0012. This State Plan Amendment ensures that the Health Insurance Premium Payment (HIPP) Program in Missouri operates in the most efficient and cost-effective manner possible by eliminating areas where Medicaid may be paying for multiple premiums on behalf of the same participant. It also operationalizes the processes the state is utilizing to move from a reimbursement model to a prospective payment model. We are pleased to inform you that SPA 22-0012 was approved on September 1, 2022, with an effective date of January 1, 2023, as requested by the state. Enclosed is a copy the approved pages for incorporation into the Missouri State Plan. If you have any questions regarding this matter you may contact Deborah Read (816) 426-5925 or by e-mail at Deborah.read@cms.hhs.gov. X Enclosures cc: Todd Richardson, SMD, MHD Becky McCarthy, MHD Sophia Hinojosa, Program Branch Manager James G. Scott, Director Division of Program Operations Sincerely, Digitally signed by James G. Scott -S Date: 2022.09.02 12:24:40 -05'00'
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-DPHV*6FRWW 'LUHFWRU'LYLVLRQRI3URJUDP2SHUDWLRQV
SHUHPDLOIURPWKHVWDWHGDWHGD SHQDQGLQNFKDQJHWRWKHQXPEHURISDJHVLV QHHGHG7KHUHDUHQRZSDJHVYHUVXV 6HSWHPEHU Digitally signed by James G. Scott -S Date: 2022.09.02 12:27:44 -05'00'
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Page 1
State Plan TN#: 22-0012
Effective Date: January 1, 2023
Supersedes TN#: 96-11
Approval Date: September 1, 2022
State Plan 4.22 Third Party Liability
Attachment 4.22-C
STATE METHODOLOGY FOR COST EFFECTIVENESS OF HEALTH PLANS
Missouri's formula for determining cost effectiveness of insurance plans under the Health Insurance Premium Payment Program (HIPP) program is modeled after the Secretary's methodology in the State Medicaid Manual, Section 3910. The formula is: Savings from the plan = GHPC - CSM
DEFINITIONS:
Health Insurance Premium Payment (HIPP) Program – The HIPP Program is a premium assistance program that Medicaid participants may be eligible for if they have access to a group health insurance plan. Missouri operates a voluntary program where participants may choose to apply to participate in the program. Missouri’s HIPP Program authority is pursuant to Section 1906 of the Social Security Act.
Group Health Insurance - any plan of, or contributed to by, an employer (including a self- insured plan) to provide health care (directly or otherwise) to the employer’s employees, former employees, or the families of the employees or former employees. A group health plan must meet section 5000(b)(1) of the Internal Revenue Code of 1986, as amended, and include continuation coverage pursuant to Title XXII of the Public Health Service Act, section 4980B of the Internal Revenue Code of 1986, or Title VI of the Employee Retirement Income Security Act of 1974, as amended.
CSM - Computer Summed Medicaid Costs: Average Medicaid expenditures (only for the services covered under the insurance plan) from the previous fiscal year, for persons with like demographic data and no third party resources, excluding Medicare.
Determine average Medicaid cost for each Medicaid-eligible person in the household by the following demographic data: 1. Age - As Tabled 2. Sex - Male/Female 3. Types of Assistance – Medicaid Eligibility (ME) Code 4. Geographic Location – Statewide average 5. Category of Service - As Tabled
GHPC - Group Health Plan Costs: Calculate total costs to the State under the group health
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State Plan TN#: 22-0012
Effective Date: January 1, 2023
Supersedes TN#: 96-11
Approval Date: September 1, 2022
plan. GHPC consists of the following formula: EP + AC = GHPC EP: Annual premium amount + annual policy cost sharing AC: Administrative Cost - $100 annually per recipient
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State Plan TN#: 22-0012
Effective Date: January 1, 2023
Supersedes TN#: 96-11
Approval Date: September 1, 2022
If the formula indicates that the policy is not cost effective based on average Medicaid expenditures for similar households, the specific health-related circumstances of the household are examined. Health insurance will be purchased if the household's anticipated medical expenditures are greater than the average and would cause the policy to be cost-effective.
TABLE OF AGE GROUPS #1 0
#2 1 - 4
#3 5 - 14
#4 15 - 19
#5 20 - 45 #6 46-65
#7 66- 79
#8 80+
TABLE OF CATEGORY OF SERVICES
Inpatient Hospital Lab & Radiology Medicare Suppl. Outpatient Hospital Ambulance Nursing Homes Physician Emergency Room Hospice Clinic DME ICF/MR Service Drugs Home Health Skilled Nurse Psychiatric / Psychology Dental Optical
Participants are not eligible for Premium Assistance if they are eligible for or enrolled in the following:
Medicare; MO HealthNet Managed Care; or Court Ordered Health Insurance.
Dental and Vision insurance policies will not be eligible for premium assistance unless the benefits are part of the medical policy and cannot be separated from the medical policy premium. Dental and Vision benefits will be provided to participants through wrap around coverage.
Payment for premiums will be made prospectively to the insurance carrier. If payment to the insurance carrier is not possible, payment will be made to the employer for employer based
(spa)(mo-22-0012)(approval-document)(page-7)Page 7#
Page 4
State Plan TN#: 22-0012
Effective Date: January 1, 2023
Supersedes TN#: 96-11
Approval Date: September 1, 2022
policies. In the event these options are not available payment may be made to the policyholder. The policyholder shall provide documentation of continuing coverage on a monthly basis.
The department shall be entitled to any refund from the health insurance carrier, due to overpayment or payment of an inactive policy, for any time period for which the department paid.
Payment for cost sharing will be made prospectively to the policyholder. The HIPP program shall be notified of upcoming Medicaid-covered services, and associated cost sharing obligations, at least three (3) weeks prior to date of service in order to receive prospective payment for any cost sharing obligation. Payment for cost sharing related to services obtained without notice to the HIPP program will be reimbursed. Documentation supporting the services occurred, and cost sharing payment made, must be submitted to the department by the end of the month following the date of service. Cost sharing payment will be made only for services obtained by Medicaid participants. Family members who are not Medicaid eligible, but are covered through the policy, are not eligible to receive payment for cost sharing.
Participants in the HIPP program are eligible for all benefits available to their eligibility group under the Medicaid state plan or section 1115 demonstration. Participants in the HIPP program will access benefits covered by both the HIPP policy and Medicaid by ensuring their providers are in-network for the HIPP policy and presenting both insurances to providers when they obtain services. If the HIPP policy does not cover a service, but Medicaid does, the participant will obtain services from a Medicaid provider.
(spa)(mo-22-0015)(approval-document)Missouri Medicaid SPA MO-22-0015: Approval Document (approved May 19, 2023, effective February 1, 2022)#
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Table of Contents State/Territory Name: Missouri State Plan Amendment (SPA) #: 22-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages
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(spa)(mo-23-0002)(approval-document)Missouri Medicaid SPA MO-23-0002: Approval Document (approved March 16, 2023, effective April 1, 2023)#
(spa)(mo-23-0002)(approval-document)(page-1)Page 1#
Table of Contents State/Territory Name: Missouri State Plan Amendment (SPA) #: 23-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages
(spa)(mo-23-0002)(approval-document)(page-2)Page 2#
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group
March 16, 2023
Mr. Todd Richardson Director MO HealthNet Division Missouri Department of Social Services P.O. Box 6500 Jefferson City, MO 65102-6500
Re: Missouri State Plan Amendment (SPA) 23-0002
Dear Mr. Richardson:
The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 23-0002. This amendment allows MO HealthNet to consider participants eligible for, but not enrolled in, a managed care plan for the Health Insurance Premium Payment (HIPP) program, and determine whether enrolling such participants in HIPP would be cost effective.
We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act at Section 1906. This letter is to inform you that Missouri Medicaid SPA 23-0002 was approved on March 16, 2023, with an effective date of April 1, 2023.
If you have any questions, please contact Michala Walker at 816-426-6503 or via email at Michala.Walker@cms.hhs.gov.
Sincerely,
James G. Scott, Director Division of Program Operations
Enclosures
cc: Glenda Kremer Becky McCarthy Marissa Crump
CENTERS FOR MEDICARE & ME0ICAI0 SERVICES CENTER FOR MEDICAID & CHIP SERVICES
(spa)(mo-23-0002)(approval-document)(page-3)Page 3#
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER 2. STATE _2 __ a_ - 2£..__ 0 __ 2 _ _ ___ MO FORM APPROVED 0MB No. 0936-0193 FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONALADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) 04/01/2023 0 NEW STATE PLAN O AMENDMENT TO BE CONSIDERED AS NEW PLAN Ii) AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transml/tal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT Section 1906 of the Social Security Act 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 4.22C, Pages 1"3 10. SUBJECT OF AMENDMENT a. FFY 2023 $ _O _____ _ b. FFY 2024 $ o 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Appl/cable) Attachment 4.22C, Pages 1-4, TN 96-44 22-0012 This amendment will allow MO HealthNet the ability to examine cases lhat are currently ineligible for the Health Insurance Premium Payment Program (HIPP) for cost effectiveness by allowing MO HeallhNet to consider participants eligible for, but not enrolled In, a Managed Care Plan for the HIPP Program. 11. GOVERNOR'S REVIEW (Check Ona) SLV Ii] GOVERNOR'S OFFICE REPORTED NO COMMENT O OTHER, AS SPECIFIED 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Y OFFICIAL 16. RETURN TO MO HealthNet Division 13. TYPEDNAME ------ ------1 P.O. Box 6500 _R_o_be_rt_J_. K_n_od_e_11 ______________ -1 Jefferson City, MO 65102 14. TITLE Acting Director 15. DATE SlJBt-.1{JTEQ' _ ..--. 1--., 1 lo/ ..) 17. DATE R.ECEIVED 2/1/23 FOR REGIONAL OFFICE USE ONLY 18. DATE APPROVED Febmai 1, 2023 March 16, 2023 PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL A ril 1, 2023 21. TYPED NAME James G. Scott Director, Division of Program Operation/ 23. REMARKS Boxes 6, 9, and 15: Changes authorized by State on 02/28/23. FOAM CMS-179 (07/92) Instructions on Back
(spa)(mo-23-0002)(approval-document)(page-4)Page 4#
State Plan TN#: 23-0003 Effective Date: April 1, 2023 Supersedes TN#: 22-0012 Approval Date: Page 1 State Plan 4.22 Third Party Liability Attachment 4.22-C STATE METHODOLOGY FOR COST EFFECTIVENESS OF HEALTH PLANS Missouri's formula for determining cost effectiveness of insurance plans under the Health Insurance Premium Payment Program (HIPP) program is modeled after the Secretary's methodology in the State Medicaid Manual, Section 3910. The formula is: Savings from the plan = GHPC - CSM DEFINITIONS: Health Insurance Premium Payment (HIPP) Program – The HIPP Program is a premium assistance program that Medicaid participants may be eligible for if they have access to a group health insurance plan. Missouri operates a voluntary program where participants may choose to apply to participate in the program. Missouri’s HIPP Program authority is pursuant to Section 1906 of the Social Security Act. Group Health Insurance - any plan of, or contributed to by, an employer (including a self- insured plan) to provide health care (directly or otherwise) to the employer’s employees, former employees, or the families of the employees or former employees. A group health plan must meet section 5000(b)(1) of the Internal Revenue Code of 1986, as amended, and include continuation coverage pursuant to Title XXII of the Public Health Service Act, section 4980B of the Internal Revenue Code of 1986, or Title VI of the Employee Retirement Income Security Act of 1974, as amended. CSM - Computer Summed Medicaid Costs: Average Medicaid expenditures (only for the services covered under the insurance plan) from the previous fiscal year, for persons with like demographic data and no third party resources, excluding Medicare. Determine average Medicaid cost for each Medicaid-eligible person in the household by the following demographic data: 1. Age - As Tabled 2. Sex - Male/Female 3. Types of Assistance – Medicaid Eligibility (ME) Code 4. Geographic Location – Statewide average 5. Category of Service - As Tabled GHPC - Group Health Plan Costs: Calculate total costs to the State under the group health March 16, 2023
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State Plan TN#: 23-0003 Effective Date: April 1, 2023 Supersedes TN#: 22-0012 Approval Date: Page 2 plan. GHPC consists of the following formula: EP + AC = GHPC EP: Annual premium amount + annual policy cost sharing AC: Administrative Cost - $100 annually per recipient If the formula indicates that the policy is not cost effective based on average Medicaid expenditures for similar households, the specific health-related circumstances of the household are examined. Health insurance will be purchased if the household's anticipated medical expenditures are greater than the average and would cause the policy to be cost-effective. TABLE OF AGE GROUPS #1 0 #2 1 - 4 #3 5 - 14 #4 15 - 19 #5 20 - 45 #6 46-65 #7 66- 79 #8 80+ TABLE OF CATEGORY OF SERVICES Inpatient Hospital Lab & Radiology Medicare Suppl. Outpatient Hospital Ambulance Nursing Homes Physician Emergency Room Hospice Clinic DME ICF/MR Service Drugs Home Health Skilled Nurse Psychiatric / Psychology Dental Optical March 16, 2023
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State Plan TN#: 23-0003 Effective Date: April 1, 2023 Supersedes TN#: 22-0012 Approval Date: Page 3 Participants are not eligible for Premium Assistance if they are eligible for or enrolled in Medicare. Participants are not eligible for Premium Assistance if they are enrolled in the following: MO HealthNet Managed Care; or Court Ordered Health Insurance. Dental and Vision insurance policies will not be eligible for premium assistance unless the benefits are part of the medical policy and cannot be separated from the medical policy premium. Dental and Vision benefits will be provided to participants through wrap around coverage. Payment for premiums will be made prospectively to the insurance carrier. If payment to the insurance carrier is not possible, payment will be made to the employer for employer based policies. In the event these options are not available payment may be made to the policyholder. The policyholder shall provide documentation of continuing coverage on a monthly basis. The department shall be entitled to any refund from the health insurance carrier, due to overpayment or payment of an inactive policy, for any time period for which the department paid. Payment for cost sharing will be made prospectively to the policyholder. The HIPP program shall be notified of upcoming Medicaid-covered services, and associated cost sharing obligations, at least three (3) weeks prior to date of service in order to receive prospective payment for any cost sharing obligation. Payment for cost sharing related to services obtained without notice to the HIPP program will be reimbursed. Documentation supporting the services occurred, and cost sharing payment made, must be submitted to the department by the end of the month following the date of service. Cost sharing payment will be made only for services obtained by Medicaid participants. Family members who are not Medicaid eligible, but are covered through the policy, are not eligible to receive payment for cost sharing. Participants in the HIPP program are eligible for all benefits available to their eligibility group under the Medicaid state plan or section 1115 demonstration. Participants in the HIPP program will access benefits covered by both the HIPP policy and Medicaid by ensuring their providers are in-network for the HIPP policy and presenting both insurances to providers when they obtain services. If the HIPP policy does not cover a service, but Medicaid does, the participant will obtain services from a Medicaid provider. March 16, 2023
(spa)(mo-23-0007)(approval-document)Missouri Medicaid SPA MO-23-0007: Approval Document (approved June 22, 2023, effective January 1, 2023)#
(spa)(mo-23-0007)(approval-document)(page-1)Page 1#
Table of Contents
State/Territory Name: Missouri State Plan Amendment (SPA) #: 23-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages
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Records / Submission Packages - View All MO - Submission Package - MO2023MS0001O - (MO-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services June 22, 2023 Todd Richardson Director MO HealthNet Division 615 Howerton Court Jefferson City, MO 65109 Re: Approval of State Plan Amendment MO-23-0007 Dear Todd Richardson, On March 31, 2023, the Centers for Medicare and Medicaid Services (CMS) received Missouri State Plan Amendment (SPA) MO-23-0007, in which Missouri proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002. We approve Missouri State Plan Amendment (SPA) MO-23-0007 with an effective date(s) of January 01, 2023. If you have any questions regarding this amendment, please contact Michala Walker at michala.walker@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services CMS Cf US JOR MEDICARE &MEDICAJO SIIMCES
(spa)(mo-23-0007)(approval-document)(page-3)Page 3#
Records / Submission Packages - View All MO - Submission Package - MO2023MS0001O - (MO-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MO2023MS0001O | MO-23-0007 CMS-10434 OMB 0938-1188 Package Header Package ID MO2023MS0001O Submission Type Official Approval Date 06/22/2023 Superseded SPA ID N/A SPA ID MO-23-0007 Initial Submission Date 3/31/2023 Effective Date N/A State Information State/Territory Name: Missouri Medicaid Agency Name: MO HealthNet Division Submission Component State Plan Amendment Medicaid CHIP 0 0 0
(spa)(mo-23-0007)(approval-document)(page-4)Page 4#
Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MO2023MS0001O | MO-23-0007 Package Header Package ID MO2023MS0001O Submission Type Official Approval Date 06/22/2023 Superseded SPA ID N/A SPA ID MO-23-0007 Initial Submission Date 3/31/2023 Effective Date N/A SPA ID and Effective Date SPA ID MO-23-0007 Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1/1/2023 MO-21-0029 Former Foster Care Children 1/1/2023 MO-13-0021 Page Number of the Superseded Plan Section or Attachment (If Applicable): Page S33
(spa)(mo-23-0007)(approval-document)(page-5)Page 5#
Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MO2023MS0001O | MO-23-0007 Package Header Package ID MO2023MS0001O Submission Type Official Approval Date 06/22/2023 Superseded SPA ID N/A SPA ID MO-23-0007 Initial Submission Date 3/31/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The intention of this SPA is to comply with the changes in 1902(a)(10((A)(i)(IX) of the Social Security Act and section 1002 of the SUPPORT Act. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2023 $10264 Second 2024 $15247 Federal Statute / Regulation Citation 42 CFR 435.150 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available
(spa)(mo-23-0007)(approval-document)(page-6)Page 6#
Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MO2023MS0001O | MO-23-0007 Package Header Package ID MO2023MS0001O Submission Type Official Approval Date 06/22/2023 Superseded SPA ID N/A SPA ID MO-23-0007 Initial Submission Date 3/31/2023 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 7/12/2023 1:38 PM EDT No comment Comments received No response within 45 days Other 0 0 0 0
(spa)(mo-23-0007)(approval-document)(page-7)Page 7#
Records / Submission Packages - View All MO - Submission Package - MO2023MS0001O - (MO-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MO2023MS0001O | MO-23-0007 CMS-10434 OMB 0938-1188 Package Header Package ID MO2023MS0001O Submission Type Official Approval Date 06/22/2023 Superseded SPA ID MO-21-0029 System-Derived SPA ID MO-23-0007 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type Individuals in 209(b) States Who Are Age 65 or Older or Who have Blindness or a Disability NEW Closed Eligibility Groups NEW
[!] S1I [!] S1il [!] Iii [!] S1il [!] [!] ■ [!] S1il [!] ■ □ □ □ □ □ ■ □ □ □ ■ 0 0 0 0 0 • 0 0 0 0 -
(spa)(mo-23-0007)(approval-document)(page-8)Page 8#
Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW
Iii 61!1 1!11 1!11 1!11 ■ □ □ □ □ □ ■ 0 0 0 0 0 0
(spa)(mo-23-0007)(approval-document)(page-9)Page 9#
Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MO2023MS0001O | MO-23-0007 Package Header Package ID MO2023MS0001O Submission Type Official Approval Date 06/22/2023 Superseded SPA ID MO-21-0029 System-Derived SPA ID MO-23-0007 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type Adult Group APPROVED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 7/12/2023 1:40 PM EDT Yes No
0 0 □ 0
(spa)(mo-23-0007)(approval-document)(page-10)Page 10#
Records / Submission Packages - View All MO - Submission Package - MO2023MS0001O - (MO-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | MO2023MS0001O | MO-23-0007 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. CMS-10434 OMB 0938-1188 Package Header Package ID MO2023MS0001O Submission Type Official Approval Date 06/22/2023 Superseded SPA ID MO-13-0021 User-Entered SPA ID MO-23-0007 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21). 3. Are described under either Section B. or C. B. Individuals Covered For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration; and b. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to B.1., the state elects to cover individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: C. Individuals Covered For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. Iii □ □
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2. In addition to C.1., the state elects to cover individuals who were in foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to a state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: a. They were enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. b. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. c. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. ~ □ □
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Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | MO2023MS0001O | MO-23-0007 Package Header Package ID MO2023MS0001O Submission Type Official Approval Date 06/22/2023 Superseded SPA ID MO-13-0021 User-Entered SPA ID MO-23-0007 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 D. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 7/12/2023 1:41 PM EDT
(spa)(mo-23-0030)(approval-document)Missouri Medicaid SPA MO-23-0030: Approval Document (approved December 30, 2023, effective January 1, 2024)#
(spa)(mo-23-0030)(approval-document)(page-1)Page 1#
Table of Contents State/Territory Name: MO State Plan Amendment (SPA) #: 23-0030 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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(spa)(mo-24-0001)(approval-document)Missouri Medicaid SPA MO-24-0001: Approval Document (approved March 15, 2024, effective January 1, 2024)#
(spa)(mo-24-0001)(approval-document)(page-1)Page 1#
Table of Contents State/Territory Name: Missouri State Plan Amendment (SPA) #: 24-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages
(spa)(mo-24-0001)(approval-document)(page-2)Page 2#
Records / Submission Packages - View All MO - Submission Package - MO2024MS0003O - (MO-24-0001) - Eligibility Summary Reviewable Units Versions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, , MO 64106 Correspondence Log I Center for Medicaid & CHIP Services March 15, 2024 Todd Richardson Director MO HealthNet Division PO Box 6500 Jefferson City, MO 651 02 Re: Approval of State Plan Amendment MO-24-0001 Dear Todd Richardson, Analyst Notes Approval Letter .., Transaction Logs News Related Actions Ms l CfN EIS FOR MEDICARE & MEDICAlO SEA\'1C£S On March 01, 2024, the Centers for Medicare & Medicaid Services (CMS) received Missouri State Plan Amendment (SPA) MO-24-0001 to provide 12 months of continuous eligibility for children under age 19 per section 5112 of the Consolidated Appropriations Act 2023. We approve Missouri State Plan Amendment (SPA) MO-24-0001 with an effective date(s) of January 01, 2024. If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cms.hhs.gov or (303) 844-7068. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services
(spa)(mo-24-0001)(approval-document)(page-3)Page 3#
Records / Submission Packages - View All MO - Submission Package - MO2024MS0003O - (MO-24-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 0MB 0938-1188 Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I MO2024MS0003O I MO-24-0001 Package Header Package ID MO2024MS0003O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID N/A State Information State/Territory Name: Missouri Submission Component O State Plan Amendment SPA ID MO-24-0001 Initial Submission Date 3/1/2024 Effective Date N/A Medicaid Agency Name: MO HealthNet Division 0 Medicaid Q CHIP ....
(spa)(mo-24-0001)(approval-document)(page-4)Page 4#
Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I MO2024MS0003O I MO-24-0001 Package Header Package ID MO2024MS0003O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID N/A SPA ID and Effective Date SPA ID MO-24-0001 Reviewable Unit Continuous Eligibility for Children Proposed Effective Date 1/1/2024 Page Number of the Superseded Plan Section or Attachment (If Applicable): SPA ID MO-24-0001 Initial Submission Date 3/1/2024 Effective Date N/A Superseded SPA ID MO2024MS0001 D
(spa)(mo-24-0001)(approval-document)(page-5)Page 5#
Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I MO2024MS0003O I MO-24-0001 Package Header Package ID MO2024MS0003O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID N/A Executive Summary SPA ID MO-24-0001 Initial Submission Date 3/1/2024 Effective Date N/A Summary Description Including The intent of this SPA is to provide 12 months of uninterrupted coverage for children per section 5112 of the Consolidated Goals and Objectives Appropriations Act 2023. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact First Second Federal Fiscal Year 2024 2025 Federal Statute I Regulation Citation 42 CFR 43S.926- Continuous eligibility for children. Amount $6020990 $8500221 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available
(spa)(mo-24-0001)(approval-document)(page-6)Page 6#
Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I MO2024MS0003O I MO-24-0001 Package Header Package ID MO2024MS0003O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID N/A Governor's Office Review 0 Nocomment 0 Comments received 0 No response within 45 days Q Other SPA ID MO-24-0001 Initial Submission Date 3/1/2024 Effective Date N/A
(spa)(mo-24-0001)(approval-document)(page-7)Page 7#
PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.5.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 3119/2024 2:42 PM EDT
(spa)(mo-24-0001)(approval-document)(page-8)Page 8#
Records / Submission Packages - View All MO - Submission Package - MO2024MS0003O - (MO-24-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log CMS-10434 0MB 0938-1188 Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Children Analyst Notes MEDICAID I Medicaid State Plan I Eligibility I MO2024MS0003O I MO-24-0001 Package Header Package ID MO2024MS0003O Submission Type Official Approval Date 03/15/2024 Superseded SPA ID MO2024MS0001 D User-Entered Approval Letter Transaction Logs News SPA ID MO-24-0001 Initial Submission Date 3/1/2024 Effective Date 1/1/2024 The state provides continuous eligibility for children in accordance with the following provisions: A. Mandatory Continuous Eligibility for Hospitalized Children Related Actions .... The state provides Medicaid to a child eligible for and enrolled under the Infants and Children under Age 19 (42 CFR 435.118) eligibility group until the end of an inpatient stay for which inpatient services are covered, if the child: 1. Was receiving inpatient services covered by Medicaid on the date the child becomes ineligible under the eligibility group based on the child's age; and 2. Would remain eligible but for attaining such age. B. Mandatory Continuous Eligibility for Children The state provides continuous eligibility to all children under age 19 and that: 1. The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends the last day of the earlier of the following periods: a. The month that the child turns 19 years old; b. 12 months. 2. Continuous eligibility is provided to children eligible under all mandatory and optional eligibility groups (excluding Medically Needy) who would otherwise lose eligibility because of any change in circumstances, unless: a. The child dies; b. The child or the child's representative voluntarily requests a termination of the child's eligibility; c. The child ceases to be a resident of the state; d. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or e. The child attains the maximum age specified in B. C. Additional Information {optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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.
(spa)(mo-24-0004)(approval-document)Missouri Medicaid SPA MO-24-0004: Approval Document (approved March 6, 2024, effective January 1, 2024)#
(spa)(mo-24-0004)(approval-document)(page-1)Page 1#
Table of Contents State/Territory Name: Missouri State Plan Amendment (SPA) #: 24-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages
(spa)(mo-24-0004)(approval-document)(page-2)Page 2#
Records / Submission Packages - View All MO - Submission Package - MO2024MS0002O - (MO-24-0004) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services March 06, 2024 Todd Richardson Director MO HealthNet Division PO Box 6500 Jefferson City, MO 65102 Re: Approval of State Plan Amendment MO-24-0004 Dear Director Richardson, On February 08, 2024, the Centers for Medicare & Medicaid Services (CMS) received Missouri State Plan Amendment (SPA) MO-24-0004, in which the state proposed to correct a typographical error that was made in MO SPA 23-0030, relating to the resource standard for a couple in the Ticket to Work Basic and Medical Improvements eligibility groups. We approve Missouri State Plan Amendment (SPA) MO-24-0004 with an effective date(s) of January 01, 2024. If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cms.hhs.gov or (303)844-7068. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services - MS amus fOR MEDIC....RE & MEDICAID SIJIVICIS
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Records / Submission Packages - View All MO - Submission Package - MO2024MS0002O - (MO-24-0004) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 CMS-10434 OMB 0938-1188 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID N/A SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date N/A State Information State/Territory Name: Missouri Medicaid Agency Name: MO HealthNet Division Submission Component State Plan Amendment Medicaid CHIP • • 0 -
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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID N/A SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date N/A SPA ID and Effective Date SPA ID MO-24-0004 Reviewable Unit Proposed Effective Date Superseded SPA ID Optional Eligibility Groups 1/1/2024 MO-23-0030 Ticket to Work Basic 1/1/2024 MO-23-0030 Ticket to Work Medical Improvements 1/1/2024 MO-23-0030
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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID N/A SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The purpose of this SPA package is to correct a typographical error on SPA ID MO-23-0030 affecting the couple resource maximum for both Ticket to Work Basic and Ticket to Work Medical Improvements groups. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2024 $0 Second 2025 $0 Federal Statute / Regulation Citation 1902(a)(10)(A)(ii)(XV) and 1902(a)(10)(A)(ii)(XVI) Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available
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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID N/A SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 3/7/2024 10:09 AM EST No comment Comments received No response within 45 days Other 0 • • •
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Records / Submission Packages - View All MO - Submission Package - MO2024MS0002O - (MO-24-0004) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 CMS-10434 OMB 0938-1188 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classifications of Individuals under Age 21 CONVERTED Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents CONVERTED Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled Yes No
- 0 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ ■ 0
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Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization NEW Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneficiaries NEW Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic APPROVED Ticket to Work Medical Improvements APPROVED Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW
[!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ ■ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 □ □ 0
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Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. Yes No • 0
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Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 3/7/2024 10:10 AM EST
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Records / Submission Packages - View All MO - Submission Package - MO2024MS0002O - (MO-24-0004) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Individuals between ages 16 and 64 with a disability, who have earned income. CMS-10434 OMB 0938-1188 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 The state covers the optional Ticket to Work basic eligibility group in accordance with the following provisions: -
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Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are at least age 16 but less than 65 years of age. 2. Have earned income. 3. But for earned income, meet the SSI definition of disability. 4. Have income and resources that do not exceed the standards established by the state.
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Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 B. Financial Methodologies 1. SSI methodologies are used in calculating household income and resources. More restrictive requirements than SSI are used in calculating countable income and/or resources. Please refer as necessary to More Restrictive Requirements than SSI under 1902(f), completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description: The first 50,000 dollars of earned income of the disabled worker's spouse is disregarded. Name of disregard: Description: Earnings of the disabled worker Earnings between 250-300% FPL of the worker with a disability. Dental and optical insurance A $75 per month standard deduction for the disabled worker's dental and optical insurance when the total dental and optical insurance premiums are less than $75. Health Insurance Premiums The amounts paid for health insurance premiums are not considered. Amount: $50.00 Description of disregard: The first $50 of the disabled worker's SSDI payments. Percentage: 50.00% Description of disregard: A standard deduction for impairment- related employment expenses equal to one-half of the disabled worker's income. Name of methodology: Description: Social Security Cost of Living Adjustment During the first quarter of each calendar year, the annual Social Security cost of living adjustment increase is disregarded. 3. Less restrictive methodologies are used in calculating countable resources. Yes No Yes No Income from household members is disregarded. Income of the spouse is disregarded. General income disregard: A specified amount of unearned income is disregarded. A percentage of earned income is disregarded. The following less restrictive methodologies are used: Yes No 0 0 0 0 □ □ □ □ □ 0 0 □
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The less restrictive resource methodologies are: Name of disregard: Description: First of the Month Resource Rule Individuals may receive coverage for the full month if they are eligible on the resource factor at any time during the month. Description of disregard: The value of a life estate is not included in determining eligibility on the basis of available resources. Name of methodology: Description: Burial Plots The value of burial plots is exempt from consideration as a resource, whether the intended use is for the individual or immediate family members, or someone else. Burial Funds In addition to financial instruments with a definite cash value, real or personal property may be designated as burial funds. Description: One vehicle, regardless of value is exempt. Additional vehicles are evaluated in accordance with the individuals needs. Description: Disregard retirement accounts including, but not limited to, individual accounts. Description: Disregard retirement accounts including, but not limited to, 401(k) and 403(b) plans. Description: Independent living accounts and medical savings accounts limited to deposits of earned income and earnings on such income while a beneficiary is a participant in this program with a value not to exceed $5000 each year. Effective January 1, 2024, an independent living account is defined as an account established and maintained to provide savings for transportation, housing, home modification, and personal care services and assistive devices associated with such beneficiary's disability. a) The $5000 exemption is available for both a medical savings account and an independent living account separately. b) The claimant may have both accounts at General resource disregard: Real property not otherwise excluded is disregarded. The state uses a less restrictive methodology with respect to resources set aside for burial. Specified methodology for the treatment of resources set aside for burial: The state uses a less restrictive methodology with respect to the treatment of motor vehicles. The value of a countable motor vehicle is totally disregarded, without limits or conditions. One motor vehicle More than one motor vehicle A motor vehicle is disregarded under specific conditions. Specified conditions: The state uses a less restrictive methodology with respect to the treatment of resources set aside in specified types of accounts. Resources set aside for retirement Individual Retirement Accounts (IRA) Tax exempt accounts - 401(k) and/or 403(b) Resources set aside in Independence/Freedom accounts □ □ □ □ □ □ □ □ □ □ □ □ □ 0 0
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the same time, in which case up to $5000 of deposits would be disregarded from each account type. c) This amount is per year and per claimant only. d) The disregard is limited to deposits of the individual's earnings while covered under this program. e) The value of the account(s) and the income earned may accrue year to year. f) The deposits must be in a separate account. Name of account: Description: Keogh and pension plans Disregard retirement accounts including, but not limited to, Keogh and pension plans. Annuities Effective October 1, 2007, and after, any stream of income resulting from investment in annuities shall be excluded as an available resource for those annuities that: ( l) Are actuarially sound as measured against the Social Security Administration Life Expectancy Tables, as amended; (2) Provide equal or nearly equal payments for the duration of the device and which exclude balloon- style final payments; (3) Provide the state of Missouri secondary or contingent beneficiary status ensuring payment if the individual predeceases the duration of the annuity, in an amount equal to the Medicaid expenditure made by the state on the individual's behalf; and (4) Name and pay the Medicaid claimant as the primary beneficiary. Specified types of accounts: A specified type of resource is disregarded: □ □
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Name of resource type: Description: Disregard of the Home ln accordance with Section 303 (f) bf P .L. 100-360, the home is not considered a resource, regardless of the value of the home. For town or city property, lots on which there is no dwelling and which adjoin the residence are considered a part of the home (regardless of the number of lots so long as they are in the same city block). For rural property, the acreage on which the home is located plus any adjoining acreage will be considered part of the home. (Property will be considered as adjoining even though a road may separate two (2) tracts.) 24 Month Disregard of the Home Disregard for 24 months a former residence of the individual in which: the individual has an equity of the appropriate resource limits if single, or if marred and living with a spouse and the individual has not lived for the past 24 months.
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Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 C. Income Standard Used The income standard for this group is: FPL 250.00% 1. No income standard 2. A percentage of the federal poverty level: 3. A percentage of the SSI Federal Benefit Rate: 4. A dollar amount 5. Other • 0 • • •
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Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 D. Resource Standard Used The resource standard for this group is: Single Individual $5000.00 Couple $10000.00 1. No resource standard 2. SSI resource standard 3. The state's more restrictive resource standard described in the More Restrictive Requirements than SSI under 1902(f) - (209(b) States) RU. 4. A dollar amount higher than the SSI resource standard • • • 0
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Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 E. Premiums and Cost Sharing Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections of the state plan.
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Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 F. Additional Information (optional) Additional information for Section D.4: Effective in FY2021, the resource limit for a single individual was increased to $5,000 and $10,000 for a couple. Beginning in FY2022 and each year thereafter, the single and couple resource limits are increased by the Consumer Price Index for All Urban Consumers or successor index published by the US Department of Labor or its successor agency, and rounded to the nearest 5 cents.
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PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 3/7/2024 10:11 AM EST
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Records / Submission Packages - View All MO - Submission Package - MO2024MS0002O - (MO-24-0004) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Ticket to Work Medical Improvements MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Employed individuals between ages 16 and 64 who are no longer disabled but still have a medical impairment. CMS-10434 OMB 0938-1188 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 The state covers the optional Ticket to Work medical improvements eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are at least age 16 but less than 65 years of age. 2. Lost eligibility for the Ticket to Work basic eligibility group because it was determined at a regular disability review that they no longer meet the disability criteria. 3. Continue to have a severe medically determinable impairment. 4. Are employed, using the following definition: 5. Have income and resources that do not exceed the standards established by the state. a. Earning at least the minimum wage and working at least 40 hours per month. b. An alternative definition • 0 -
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Ticket to Work Medical Improvements MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 B. Financial Methodologies 1. SSI methodologies are used in calculating household income and resources. More restrictive requirements than SSI are used in calculating countable income and/or resources. Please refer as necessary to More Restrictive Requirements than SSI under 1902(f), completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description: The first 50,000 dollars of earned income of the disabled worker's spouse is disregarded. Name of disregard: Description: Earnings of the disabled worker Earnings between 250-300% FPL of the worker with a disability. Dental and optical insurance A $75 per month standard deduction for the disabled worker's dental and optical insurance when the total dental and optical insurance premiums are less than $75. Health Insurance Premiums The amounts paid for health insurance premiums are not considered. Amount: $50.00 Description of disregard: The first $50 of the disabled worker's SSDI payments. Percentage: 50.00% Description of disregard: A standard deduction for impairment- related employment expenses equal to one-half of the disabled worker's income. Name of methodology: Description: Social Security Cost of Living Adjustment During the first quarter of each calendar year, the annual Social Security cost of living adjustment increase is disregarded. 3. Less restrictive methodologies are used in calculating countable resources. Yes No Yes No Income from household members is disregarded. Income of the spouse is disregarded. General income disregard: A specified amount of unearned income is disregarded. A percentage of earned income is disregarded. The following less restrictive methodologies are used: Yes No 0 0 0 0 □ □ □ □ □ 0 0 □
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The less restrictive resource methodologies are: Name of disregard: Description: First of the Month Resource Rule Individuals may receive coverage for the full month if they are eligible on the resource factor at any time during the month. Description of disregard: The value of a life estate is not included in determining eligibility on the basis of available resources. Name of methodology: Description: Burial Plots The value of burial plots is exempt from consideration as a resource, whether the intended use is for the individual or immediate family members, or someone else. Burial Funds In addition to financial instruments with a definite cash value, real or personal property may be designated as burial funds. Description: One vehicle, regardless of value is exempt. Additional vehicles are evaluated in accordance with the individuals needs. Description: Disregard retirement accounts including, but not limited to, individual accounts. Description: Disregard retirement accounts including, but not limited to, 401(k) and 403(b) plans. Description: Independent living accounts and medical savings accounts limited to deposits of earned income and earnings on such income while a beneficiary is a participant in this program with a value not to exceed $5000 each year. Effective January 1, 2024, an independent living account is defined as an account established and maintained to provide savings for transportation, housing, home modification, and personal care services and assistive devices associated with such beneficiary's disability. a) The $5000 exemption is available for both a medical savings account and an independent living account separately. b) The claimant may have both accounts at General resource disregard: Real property not otherwise excluded is disregarded. The state uses a less restrictive methodology with respect to resources set aside for burial. Specified methodology for the treatment of resources set aside for burial: The state uses a less restrictive methodology with respect to the treatment of motor vehicles. The value of a countable motor vehicle is totally disregarded, without limits or conditions. One motor vehicle More than one motor vehicle A motor vehicle is disregarded under specific conditions. Specified conditions: The state uses a less restrictive methodology with respect to the treatment of resources set aside in specified types of accounts. Resources set aside for retirement Individual Retirement Accounts (IRA) Tax exempt accounts - 401(k) and/or 403(b) Resources set aside in Independence/Freedom accounts □ □ □ □ □ □ □ □ □ □ □ □ □ 0 0
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the same time, in which case up to $5000 of deposits would be disregarded from each account type. c) This amount is per year and per claimant only. d) The disregard is limited to deposits of the individual's earnings while covered under this program, and any earnings on these deposits. e) The value of the account(s) and the income earned may accrue year to year. f) The deposits must be in a separate account. Name of account: Description: Keogh and pension plans Disregard retirement accounts including, but not limited to, Keogh and pension plans. Annuities Effective October 1, 2007, and after, any stream of income resulting from investment in annuities shall be excluded as an available resource for those annuities that: ( l) Are actuarially sound as measured against the Social Security Administration Life Expectancy Tables, as amended; (2) Provide equal or nearly equal payments for the duration of the device and which exclude balloon- style final payments; (3) Provide the state of Missouri secondary or contingent beneficiary status ensuring payment if the individual predeceases the duration of the annuity, in an amount equal to the Medicaid expenditure made by the state on the individual's behalf; and (4) Name and pay the Medicaid claimant as the primary beneficiary. Name of resource type: Description: Disregard of the Home In accordance with Section 303 (f) bf P .L. 100-360, the home is not considered a resource, regardless of the value of the home. For town or city property, lots on which there is no dwelling and which adjoin the residence are considered a part of the home (regardless of the number of lots so long as they are in the same city block). For rural property, the acreage on which the home is located plus any adjoining acreage will be considered part of the home. (Property will be considered as adjoining even though a road may separate two (2) tracts.) 24 Month Disregard of the Home Disregard for 24 months a former residence of the individual in which: the individual has an equity of the appropriate resource limits if single, or if marred and living with a spouse and the individual has not lived for the Specified types of accounts: A specified type of resource is disregarded: □ □
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Name of resource type: Description: past 24 months.
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Ticket to Work Medical Improvements MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 C. Income Standard Used The income standard for this group is: 250.00% FPL 1. No income standard 2. A percentage of the federal poverty level: 3. A percentage of the SSI Federal Benefit Rate: 4. A dollar amount 5. Other • 0 • • •
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Ticket to Work Medical Improvements MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 D. Resource Standard Used The resource standard for this group is: Single Individual $5000.00 Couple $10000.00 1. No resource standard 2. SSI resource standard 3. The state's more restrictive resource standard described in the More Restrictive Requirements than SSI under 1902(f) - (209(b) States) RU. 4. A dollar amount higher than the SSI resource standard • • • 0
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Ticket to Work Medical Improvements MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 E. Premiums and Cost Sharing Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections of the state plan.
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Ticket to Work Medical Improvements MEDICAID | Medicaid State Plan | Eligibility | MO2024MS0002O | MO-24-0004 Package Header Package ID MO2024MS0002O Submission Type Official Approval Date 03/06/2024 Superseded SPA ID MO-23-0030 System-Derived SPA ID MO-24-0004 Initial Submission Date 2/8/2024 Effective Date 1/1/2024 F. Additional Information (optional) Additional information for Section D.4: Effective in FY2021, the resource limit for a single individual was increased to $5,000 and $10,000 for a couple. Beginning in FY2022 and each year thereafter, the single and couple resource limits are increased by the Consumer Price Index for All Urban Consumers or successor index published by the US Department of Labor or its successor agency, and rounded to the nearest 5 cents.
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PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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. This view was generated on 3/7/2024 10:13 AM EST
(spa-index)(p01)Missouri Medicaid state plan amendments on medicaid.gov: SPA index page 1 of 3#
(spa-index)(p01)(block-1)Medicaid State Plan Amendments#
This plan amendment updates the inpatient reimbursement methodology, the methodology for the supplemental payments, and the methodology for the Disproportionate Share Hospital (DSH) payment.
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Health Home PMPM rate. This state plan amendment increases the per member per month from $79.51 to $98.59 effective August 1, 2025.
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The purpose of this plan amendment update Missouri’s school-based reimbursement methodology to align with CMS guidance using a cost-based payment approach.
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Missouri amended its approved Primary Care Health Homes (PCHH) state plan to add a community health worker and an optional behavioral health assistant as members of the care team to be paid under the per member per month (PMPM) payment.
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The purpose of this SPA is to revise the rate methodology for the Amount Would Othe1wise be PAID (AWOP) and capitation rates for the Program of All-Inclusive Care for the Elderly (PACE) to better align with the with the state's development processes. It will also establish the option to implement a value-based payment (VBP) program to provide quality-based incentives to the PACE organizations.
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This State Plan Amendment gives a two-year extension of the exception from establishing a Medicaid Recovery Audit Contractor (RAC) program.
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This amendment revises the Medication Assisted Treatment (MAT) pages of the State Plan to make the coverage permanent as required by the Consolidated Appropriations Act of 2024.
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This State Plan Amendment adds coverage for ground ambulance emergency transportation to Behavioral Health Crisis Centers (BHCC) for individuals experiencing a behavioral health crisis.
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This SPA added Applied Behavior Analysis (ABA) and Transcranial Magnetic Stimulation (TMS) services to the Comprehensive Substance Treatment and Rehabilitation (CSTAR) program.
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The purpose of this plan amendment is to reimburse ophthalmologists eighty five (85%) of the Missouri Locality 01, 2023 rates.
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This amendment streamlines the requirements for Diabetes Prevention Program services to remove administrative burden for providers, improve accessibility of services for participants and correct the fee schedule link.
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The purpose of this plan amendment is to increase the fee schedule for anesthesia services.
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This plan amendment updates the cost report total Case Mix Index (CMI), provides for replacement facilities to be designated as new or existing consistent with the criteria used for other new or existing nursing facilities, updates the value-based purchasing (VBP) quality measures and the corresponding per diem adjustments, clarifies the base rate for new facilities having their initial prospective rate set, and provides for the multiple component incentive to be recalculated with the semi-annual and annual rate updates.
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The purpose of this plan amendment is to add a Prospective Payment System (PPS) and an Alternative Payment Method for Provider Based Rural Health Clinics (PBRHCs).
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This amendment streamlines requirements for the Biopsychosocial Treatment of Obesity program to remove administrative burden to improve accessibility of services for participants.
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This amendment adds a daily reimbursement amount for services provided at a licensed Prescribed Pediatric Extended
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This SPA accept Medicaid eligibility decisions made by the Exchange or other agencies administering insurance affordability programs and to furnish Medicaid in to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for Medicaid.
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This amendment adds doula services to the alternative benefit plan.
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This Amendment updates state plan assurances in accordance with federally mandated quality reporting requirements for the Child Core Set and the behavioral health quality measures on the Adult Core Set outlined in 42 CFR 431.16 and 437.10 through 437.15.
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This plan amendment provides for a rebasing and other updates for nursing facility and HIV nursing facility per diem rates.
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This SPA adds language to the State Plan page attesting that the state is in compliance with the Federal Upper Limit (FUL) requirements for multiple source drugs.
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This plan amendment reimburses ophthalmologists eighty-five (85%) percent of the 2024 Missouri Locality 01 Medicare Rates.
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This amendment updates the Medicare fee schedules, MO HealthNet fee schedules, and the National Dental Advisory Service (NDAS) used to determine outpatient reimbursement rates.
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This amendment adds coverage of doula services to enhance the bi1ihing experience, reduce complications, and improve outcomes for women and infants.
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This plan amendment increases certain rates for physician, dental, podiatry, x-ray, lab, family planning, EPSDT, emergency ambulance, and home health services.
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This Amendment complies with the final rule that requires Health Home Core Set(s) to be a mandatory reporting element beginning 2024 pursuant to 42 CFR §§ 437.10 and 437.15.
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This Amendment complies with the final rule that requires Health Home Core Set(s) to be a mandatory reporting element beginning 2024 pursuant to 42 CFR §§ 437.10 and 437.15.
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This amendment will comply with the final rule that requires Health Home Core Set(s) to be a mandatory reporting element beginning 2024 pursuant to 42 CFR §§ 437.10 and 437.15.
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This plan amendment establishes reimbursement methodology for Behavioral Health Integration Services.
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This plan amendment updates the definition of a safety net hospital and updates the Acuity Adjustment Payment and Stop Loss Payment methodologies.
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This state plan amendment incentivizes DD TCM staff to complete the Person-Centered Thinking (PCT) and the Fatal Five for Case Managers training to improve the quality of care and quality of life for individuals with developmental disabilities.
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The SPA implements a 90-day grace period for behavior technicians to be covered under the other licensed practitioner Medicaid benefit while working to acquire the Registered Behavior Technician credential.
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This state plan amendment updates the MO Healthnet fee schedule to add reimbursement for manual and electric breast pumps.
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This SPA changes the MO HealthNet Dental Program to allow eligible MO HealthNet participants aged 21 and older to receive periodic oral evaluations. The SPA also allows MO HealthNet-enrolled dental providers to provide and receive reimbursement for the evaluations rendered.
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This SPA adds coverage of prescribed drugs that are not covered outpatient drugs in cases of a drug shortage.
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This SPA adds coverage of developmental disabilities health homes services to the Alternative Benefit Plan.
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This Amendment implements a Developmental Disabilities Health Home (DD Health Home) for individuals statewide served through the Missouri Department of Mental Health, Division of Developmental Disabilities (DD), who have a qualifying chronic health condition, have or are at risk of developing another condition, and are eligible for Division of DD services.
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This amendment is to provide 12 months of continuous eligibility for children under age 19 per section 5112 of the Consolidated Appropriations Act 2023.
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This SPA corrects a typographical error that was made in MO SPA 23-0030, relating to the resource standard for a couple in the Ticket to Work Basic and Medical Improvements eligibility groups.
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This amendment gives a 2-year exception to the recovery audit contractor (RAC) until April 1, 2026.
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The SPA allows doctoral level psychology interns under the supervision of a licensed psychologist to provide services for MO HealthNet participants.
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Annual assurance of the pharmacy program's adherence to the FULs requirement of federal regulation regarding expenditures for multiple source drugs.
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This State Plan Amendment is adding back language related to final DSH redistributions and adding language regarding final DSH redistributions and unspent allotment payments to bankrupt-liquidation and closed hospitals.
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State made changes to several to the income and resource disregards applied in the eligibility determinations for the optional Ticket to Work and Work Incentives Improvement Act (WEEIAA) eligibility group.
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Provides per diem increase of $10.00 for all nursing facilities.
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The State provides for coverage of a maximum of twelve reserve bed days for the first six calendar months and 12 days for the second six calendar months of the year for recipient residents of Title XIX nursing facilities for the purpose of therapeutic home visits. The absence must be specifically provided for in the patient's plan of care and physician prescribed.
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private PRTF services due to increase appropriated by state legislature
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This SPA adds language to attest of the coverage of all approved Advisory Committee on Immunization Practices (ACIP) adult vaccines and their vaccine administration.
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This SPA provides Missouri with approval to provide 12 months of continuous postpartum coverage to individuals enrolled in its Medicaid program.
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This SPA authorizes increased federal financial participation (FFP) for newly-eligible individuals receiving postpartum coverage and further includes the addition of Attachment D, which describes the special circumstances and other proxy adjustments that are applied to account for the proportion of individuals covered under the extended postpartum coverage option who would otherwise be eligible for coverage in the adult group and for the newly eligible FFP under section 1905(y) of the Social Security Act;
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This State Plan Amendment is updating the inpatient hospital reimbursement to include a new supplemental payment. The new supplemental payment is the Psych Adjustment Payment.
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This state plan amendment increases EPSDT/Private Duty Nursing and Personal Care rates.
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This Amendment allows for the changes in the practitioners qualified to perform the services and minor language updates.
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On August 1, 2023, the Centers for Medicare and Medicaid services (CMS) received Missouri State Plan Amendment(SPA) MO-23-0014 to increase the Care Coordination component of the Primary Care Health Home Per-Member-Per-Month rate.
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This amendment allows Licensed Psychologists, Licensed Behavior Analysts, and Licensed Assistant Behavioral Analysts that work in states that border Missouri to provide Applied Behavioral Analysis services to Missouri Medicaid participants.
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This state plan amendment adds language to reimburse ambulatory surgical centers (ASC) from a fee schedule based on Medicare’s ASC Payment System.
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This state plan amendment updates the Medicare fee schedules, MO Healthnet fee schedules and the National Advisory Service (NDAS) used to determine outpatient reimbursement rates.
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This amendment allows occupational therapy assistants, physical therapy assistants, and speech language pathology assistants to enroll as MO HealthNet providers and bill for covered services provided to eligible MO HealthNet participants.
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Annual assurances of the pharmacy program adherence to the requirement of federal regulations regarding expenditures for multiple source drugs.
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This State Plan Amendment includes the following revisions to Certified Community Behavioral Health services:
Removes face-lo-face requirement in order to constitute a visit;
Adds telemedicine and mobile unit as a place of service;
Clarifies definition of crisis intervention;
Updates practitioners who can provide services and also name of practitioner with;
Adds Resident Physician as a qualifying practitioner; and,
Updates rate methodology pages for effective date rate methodology for initial payment rates and for rate reconsiderations, and quality incentive payment.
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(spa-index)(p02)Missouri Medicaid state plan amendments on medicaid.gov: SPA index page 2 of 3#
(spa-index)(p02)(block-1)Medicaid State Plan Amendments#
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Effective December 16, 2018, this amendment brings Missouri into compliance with items contained in the reimbursement requirements for the Covered Outpatient Drug final rule with comment period (CMS-2345-FC) and includes: reimbursement rates for long-term care, specialty drugs, drugs purchased at a nominal price, and physician administered drugs and reimbursement methods that use, among others, the National Average Drug Acquisition Cost (NADAC) for covered outpatient drugs.
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SPA was submitted to request a waiver of the regulatory requirement at 42 CFR 455, Subpart F to enter into a contract with a Medicaid Recovery Audit Contractor (RAC) vendor to identify over-payments and underpayments and to recoup over-payments.
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Proposes to update the provider fee schedule to add behavioral health services with an effective date of January 1, 2020
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This time-limited state plan amendment responds to the COVID-19 national emergency. The purpose of this amendment is to allow 12 months continuous eligibility for children under age 19, waive cost sharing for testing services, modify the enforcement of premium and spend down obligations during the emergency period for certain populations, and allow exceptions to the preferred drug list if shortages occur.
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This SPA is an adding cost-based reimbursement process for school-based IEP specialized transportation services based on certified public expenditures.
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SPA This adds language allowing the department to cover services by Licensed Professional Counselors and Licensed Marital and Family Therapists in a Federally Qualified Health Center and a Rural Health Center.
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Allows the state to provide alternative therapies for the management of chronic pain by using medical alternative therapy and non-opioid pharmacologic therapy for adults participants.
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This amendment decreases non-state operated intermediate care facility for individuals with intellectual disabilities ( ICF-IID) per diem rates.by 2.82 percent.
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Amends the provisions governing clinic services to clarify which providers are allowed to provide Community Mental Health Center services.
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Reasonable classifications of children This SPA clarifies coverage in place in the state as of December 31, 2013.
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(spa-index)(p03)Missouri Medicaid state plan amendments on medicaid.gov: SPA index page 3 of 3#
(spa-index)(p03)(block-1)Medicaid State Plan Amendments#
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This amendment provides for a per diem increase to nursing facility and H IV nursing facility reimbursement rates by granting a one dollar and twenty-five cents ($1.25) increase to the current per diem rate\effective for dates of service beginning July 1, 2014.
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This amendment provides the State Fiscal Year (SFY) 2012 trend factor; clarifies new federal audit and record retention requirements in accordance with federally mandated DSH audit standards; references new payment methodologies relating to Disproportionate Share (DSH) and Upper Payment Limit (UPL) payments; and revises when Enhanced Graduate Medical Education (GME) payments are paid to hospitals.
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This amendment provides the State Fiscal Year (SFY) 2011 trend factor and specifies that it will not be applied in determining payments; clarifies the per diem rate, Direct Medicaid payments and uninsured payments for facilities that do not have a fourth prior year base cost report and facilities previously certified for MO HealthNet that had terminated and are reopening; indicates the Missouri Specific Trend Factor will not be applied in determining payments; clarifies the safety net adjustment relating to the uninsured payment for Department of Mental Health facilities; and, specifies the process to be used in finalizing DSH payments as a result of the findings of the federally-mandated DSH audits.
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