Understanding Types of Medicaid

To receive MO HealthNet a person must meet the eligibility requirements of one of the following groups: 

• age 65 or over (referred to as aged)
• blind
• disabled
• adults age 19-64
• a child under age 19 (or age 22, if in state custody)
• a pregnant woman
• a woman in need of treatment for breast or cervical cancer
• an individual under age 26 who was in foster care on the date they turned age 18 or 30 days prior

and

• Meet the requirements of an eligibility category - see the links below

All MO HealthNet eligibility requirements for MO HealthNet for the aged, blind, disabled, and breast/cervical cancer groups.

All MO HealthNet eligibility requirements for Family Healthcare Programs.

Income and asset (resource) limit guidelines for MO HealthNet for the aged, blind, disabled, and breast/cervical cancer groups.

Annual income guidelines for all programs

CHIP Premium Chart.

MO HealthNet Eligibility (ME) codes identify the category of MO HealthNet that a person is in. There are currently 68 ME codes in use.

• 8 are state only funded (no federal Medicaid match) with a limited benefit package
• 10 have a benefit package restricted to specific services
• 5 are the Children’s Health Insurance Program (CHIP) premium program
• The others are federally matched categories that provide a benefit package based on whether the person is a child, an adult, pregnant, blind, or in a nursing facility

The Provider Resource Guide contains MO HealthNet division contact information including provider communication, pharmacy/clinical services, exception process, participant services, and a list of ME Codes with benefit package information.  

MO HealthNet Eligibility (ME) Codes in regards to DMH Consumers  - A list with information about which ME Codes cover DMH services, and which are in managed care plans. 

Includes coverage for:

• primary, acute and preventive care,
• hospital care,
• prescriptions,
• dental and vision care,
• comprehensive psychiatric rehabilitation (CPR),
• comprehensive substance treatment and rehabilitation (CSTAR),
• home health care,
• occupational, physical, and speech therapy,
• home and community based waiver services,
• hearing aids,
• non-emergency medical transportation (NEMT), and
• transplants.

Call the MO HealthNet Participant Services Unit,1-800-392-2161, to find out if a specific procedure is covered

Children and young adults under age 21 receive the full comprehensive benefit package, unless they are:

• In the CHIP premium program (ME codes 73,74,75,97, 9S). The CHIP premium program covers all services in the full comprehensive benefit package except NEMT.  
• In  a state only funded category
  • (ME codes 02, 08, 52, 57, 64, 65, 0F, 5A).  
• In a specific restricted benefit package
  • (ME codes 55, 58, 59, 80, 82, 89, 91, 92, 93, 94)

Adults age 21 and over who are receiving federally matched Medicaid based on blindness (ME codes 03, 12, 15), pregnancy (ME codes 18, 43, 44, 45, 61, 95, 96, 98), or are in a Medicaid vendor nursing facility receive the full comprehensive benefit package, except:

• occupational, physical, and speech therapy are only covered as an outpatient hospital or home health service;
• private duty nursing is not covered;
• social worker/counselor services are not covered;
• dental does not include orthodontics;
• vision care for pregnant women is limited to one exam per year and glasses are limited to one pair every two years.

Adults (age 21 and over) receiving federally matched Medicaid who are not in a nursing facility or receiving  based on blindness or pregnancy have a “limited benefit package”.  The coverage limitations are:  

• dental is limited to specific services;
• diabetes self-management training is not covered;
• hearing aids are not covered;
• physical, occupational, and speech therapy are not covered;
• eye exams are only covered once every two years.

The benefit package for the Adult Expansion Group (ME Code E2) is the same as the package for other Medicaid participants ages 19 through 64, except: 

• DMH Developmental waiver services and Home and Community Based (HCB) waiver services authorized by DHSS are not covered. 

E2 participants ages 19 and 20 receive the Full Medicaid Comprehensive Benefit Package.

E2 participants ages 19 through 64 receive the Limited Benefit Package for Adults. 

The state only funded categories Blind Pension (02), CWS Foster Care (08), Foster Care Title IV-E/Independent-Former Foster Care (18-25) in an IMD (0F), DYS General Revenue (52), CWS-FC Adoption Subsidy (57), Adoption Subsidy Title IV-E in an IMD (5A), and Group Home Health Initiative Fund (64,65) cover all services except:

• CPR,
• CSTAR,
• non-emergency medical transportation (NEMT),
• transplants, and
• home and community based waiver services (authorized by DMH Division of Developmental Disabilities or Department of Health and Senior Services).

• QMB (ME 55) covers only Medicare premiums, coinsurance and deductibles.  
• Presumptive Eligibility for Pregnant Women (ME 58,59,94) covers only out-patient pre-natal care.
• Uninsured Women’s Health Services (ME 80,89) only covers family planning and testing for STDs.
• Gateway to Better Health (ME 91,92,93) provides coverage at participating health care clinics in St. Louis for preventative, family, and well care; some dental care; and generic prescriptions dispensed at the clinic.
• Missouri Rx (ME 82) pays 50% of Medicare Part D prescription drug co-payments.

Coverage from MO HealthNet Fee-for-Service providers for all categories for:

• the aged (65+) – ME codes 01,11,14
• blind – ME codes 02,03,12,15
• people with disabilities – ME codes 04,13,16,23,33,34, 41,85,86  
• women receiving breast or cervical cancer treatment – ME codes 83, 84 
• presumptive eligibility:  ME codes 58,59,87,94

Coverage from a MO HealthNet Managed Care plan for:

• FSD family healthcare categories for children, pregnant women, families, and refugees:
  • ME codes E2, 05, 06, 10, 18, 40, 43, 44, 45, 60, 61, 62, 65, 71, 72, 73, 74, 75 ,95, 96, 97, 98, 4M, 6S, 9S
• DSS Children’s Division and Division of Youth Services categories for foster care, adoption subsidy, and other state custody -
  • ME codes 07, 08, 29, 30, 36, 37, 38, 50, 52, 56, 57, 63, 64, 66, 68, 69, 70, 0F, 5A

Participants in these categories have the option of opting out of managed care and switching to fee-for-service if they have a disability.  

The following services are excluded from managed care and are always covered fee-for-service:

• CPR,
• CSTAR,
• Prescription medications,
• Targeted case management,
• Transplants,
• home and community based waiver services (authorized by DMH Division of Developmental Disabilities or Department of Health and Senior Services),
• Occupational, physical, and speech therapy in an IEP,
• Applied Behavior Analysis for Autism Spectrum Disorder

For children state custody or adoption subsidy, all behavioral health services are covered fee-for-service.

CPR, CSTAR, and DD waiver services are covered by all ME codes except the following that are either state only funded (*) or have a specific restricted benefit package(^).

• 02* – Blind Pension
• 08* – CWS Foster Care
• 0F* – Foster Care Title IV-E/Independent-Former Foster Care (18-25) in an IMD
• 52* – DYS General Revenue
• 55^ – QMB
• 57* – CWS-FC Adoption Subsidy
• 5A* – Adoption Subsidy Title IV-E in an IMD 
• 58^, 59*^ – Presumptive Eligibility for Pregnant Women
• 94^ – Presumptive Eligibility for Show Me Healthy Babies
• 64*,65* - Group Home Health Initiative Fund
• 80^, 89^ – Uninsured Women’s Health Services
• 91^, 92^, 93^ – Gateway to Better Health
• 82*^ – Missouri Rx 

ME Code E2 - Adult Expansion Group (AEG) does NOT cover DD waiver services, but does cover CPR and CSTAR.