Amendment number 6 to the Medicaid Managed Care Eastern Region contract between the State of Missouri Office of Administration Division of Purchasing and Materials Management and Harmony Health Plan of Illinois, Inc

  TO:   

HARMONY HEALTH PLAN INC

23 PUBLIC SQUARE STE 400

BELLEVILLE, IL 62220

d.

State Child Health Plan: Missouri submitted a combination State Child Health Plan under Title XXI of the Social Security Act for the State Children's Health Insurance Program (SCHIP) May 31, 2007. The Centers for Medicare and Medicaid Services (CMS) approved Missouri's SCHIP State Child Health Plan on September 28, 2007, with an effective date of September 1, 2007. Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. Missouri's SCPIIP State Child Health Plan uses funds provided under Title XXI to both expand benefits under Missouri's State Medicaid Plan, and to obtain coverage that meets the requirements for a separate child health program.

1)

SCHD - Non Premium - Missouri provides presumptive eligibility for children in families with income of 150% of the FPL or below until a decision is made on regular SCHIP eligibility. Uninsured children age birth through age 18 with family income less than 150% of the FPL are covered.

 

Children eligible for the Non - Premium Program receive a benefit package of essential medically necessary health services, including Non-Emergency Medical Transportation (NEMT). Prescription drugs will be subject to the national drug rebate program requirements. Fee-for-service will be utilized in regions where MO HealthNet managed care is not yet available. When MO HealthNet managed care begins in these areas, Title XXI eligibles will be enrolled in MO HealthNet managed care. No new eligible will be excluded because of pre­existing illness or condition.

2)

SCHIP - Premium - Uninsured children age birth through age 18 with family income between 151% and 300% of the FPL are covered under a Separate Child Health Program under a Title XXI SCHIP State Plan. No new eligible is excluded because of pre-existing illness or condition. Children in families with income more than 150% of FPL are not eligible if they have access to affordable insurance.

 

Children eligible for the Premium Program receive a benefit package of essential medically necessary health services, excluding NEMT. Prescription drugs are subject to the national drug rebate program requirements. Fee-for-service is utilized in regions where MO HealthNet managed care is not yet available. When MO HealthNet Managed Care begins in these areas, Title XXI eligibles will be enrolled in MO HealthNet Managed Care.

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Furnish to the Department of Social Services the uninsured child's social security number or numbers, if the uninsured child has more than one such number;

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Furnish to the Department of Social Services the uninsured child's documentation of citizenship and alien status;

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Cooperate with the Department of Social Services in identifying and providing the information to assist the MO HealthNet Division in pursuing any third-party health insurance carrier who may be liable to pay for health care;

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Cooperate with the Department of Social Services, Family Support Division in establishing paternity and in obtaining support payments, including medical support;

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Demonstrate, upon request, their child's participation in wellness programs including immunizations and a periodic physical examination. (This shall not apply to any child whose parent or legal guardian objects in writing to such wellness programs including immunizations and an annual physical examination because of religious beliefs or medical contraindications);

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Demonstrate annually that their total net worth does not exceed two hundred fifty thousand dollars in total value;

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The Premium Program requires a premium, but does not impose co-payments, co­insurance, or deductibles; and

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There will be protections for the Premium population against dropping or foregoing private coverage, including a six (6) month waiting period and insurance availability screens through the MO HealthNet's Health Insurance Premium Payment (HIPP) program.

Any child identified as having special health care needs defined as a condition which left untreated would result in the death or serious physical injury of a child, that does not have access to affordable employer-subsidized health care insurance will be exempt from the requirement to be without health care coverage for six months in order to be eligible for services; and

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A child shall not be subject to the 30-day waiting period as long as the child meets all other qualifications for eligibility.

 

e. MO Health Net managed care eligibles in the above specified eligibility groups may voluntarily disenroll from the Managed Care Program or choose not to enroll in the Managed Care Program if they:

 

1)     Are eligible for Supplemental Security Income (SSI) under Title XVI of the Social Security Act;

1)

The health plan shall conduct HCY/EPSDT well child visits on all eligible members under age twenty-one (21) to identify health and developmental problems. The state agency recognizes that the decision to not have a child screened is the right of the parent or guardian of the child. For those children that have not had well child visits in accordance with the periodicity schedule established by the state agency, the health plan shall document its outreach and educational efforts to the parent or guardian informing them of the importance of well child visits, that a well child visits is due, that appointment scheduling assistance is available, and that transportation (except to those children with ME Codes 73-75) is available. (The current periodicity schedule is contained in Attachment 3.) The health plan shall follow the MO HealthNet fee-for-service policies for recognition of completion of all components of a full medical HCY/EPSDT well child visit service. A full HCY/EPSDT well child visits includes all of the components listed below. A partial well child visit includes the first six (6) components listed below. The last three (3) components are individual screens. An interperiodic screen is defined as any encounter with a health care professional acting within his or her scope of practice.

  

• A comprehensive health and developmental history including assessment of both physical and mental health developments;

• A comprehensive unclothed physical exam;

• Health education (including anticipatory guidance);

5)

The health plan shall have an established process for reminders, follow-ups, and outreach to members. This process shall include, but not be limited to, notifying the parent(s) or guardian(s) of children of the needs and scheduling of periodic well child visits according to the periodicity schedule. The health plan shall provide assistance to new members in accessing HCY/EPSDT well child visit services within ninety (90) calendar days of health plan enrollment. The health plan shall provide assistance to members in accessing subsequent HCY/EPSDT well child visits in accordance with the periodicity schedule. At the time of notification, the health plan shall offer transportation and scheduling assistance if necessary. For members with ME Codes 73 through 75, non-emergency medical transportation is not a covered benefit.

 

2.7.2 The health plan shall include all the services specified in the comprehensive benefit package with the exception of non-emergency medical transportation (NEMT) for uninsured children in ME Codes 73-75 (Refer to Attachment 1, COA 5) and children in state custody with the following ME Codes 08, 52, 57, and 64 (Refer to Attachment 1, COA 4).