- (ME codes 02, 08, 52, 57, 64, 65, 0F, 5A).
- (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.
State Only Category Benefit Packages
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
- 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.
Managed Care Exclusions
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.
Categories that Don't Cover DMH Services
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.
FSD Eligibility Categories • MO HealthNet for the Aged, Blind, Disabled (MHABD) – includes spend down/non-spend down, vendor nursing facility, HCB Special Income Limit (SIL), 1619(a)&(b), disabled children
o ME codes 11 (age 65 & over), 12 (blind), 13 (disabled)
• Ticket-to-Work Health Assurance (TWHA)
o ME codes 85 (premium), 86 (non-premium)
• Supplemental Nursing Care (SNC)
o ME codes 14 (age 65 & over), 15 (blind), 16 (disabled)
• Supplemental Aid to the Blind (SAB) & Aid to the Blind conversion (AB)
• Blind Pension (BP)
• MOCDD (Sara Lopez) waiver SIL category
o ME codes 33, 34
• Old Age Assistance conversion (OAA)
• Aid to the Permanently and Totally Disabled conversion (PTD)
• Aid to the Blind conversion (AB)
• Qualified Medicare Beneficiary (QMB)
• Missouri Rx
o ME code 82 (only benefit is payment of half of Medicare Part D co-pays)
• Specified Low Income Medicare Beneficiary (SLMB or SLMB1)
o no ME code as only benefit is payment of Medicare premium
• Qualifying Individual (QI or SLMB2)
o no ME code as only benefit is payment of Medicare premium
• MO HealthNet for Families (MHF) includes Transitional Medical Assistance
o ME code 05 for caretakers, 06 for children
• MO HealthNet for Kids (MHK)
o ME codes 40, 62, 71, 72 (non-premium) 73, 74, 75 (CHIP premium)
• MO HealthNet for Pregnant Women (MPW)
o ME codes 18, 43, 44, 45, 61
• Newborns
• Show Me Healthy Babies
o ME codes 95, 96, 98
• Show Me Healthy Babies Newborns
• MO HealthNet for Women Receiving Breast or Cervical Cancer Treatment (BCCT)
o ME codes 83, 84
• Refugee Medical Assistance (program ended 11/30/18)
o ME codes 10, 19, 21, 24, 26
• Presumptive Eligibility for Kids
• Temporary MO HealthNet for Pregnant Women (TEMP) also known as Presumptive Eligibility for Pregnant Women
o ME codes 58, 59, 94
• MO HealthNet for Kids in a Vendor Institution
o ME Codes 23, 41
• Uninsured Women's Health Services
o ME Codes 80, 89
• Children Division Programs
o ME Codes 07, 08, 30, 36, 37, 38, 56, 57, 64, 66, 69, 70, 88
• Division of Youth Services Programs
o ME Codes 29, 50, 52, 68
• Gateway to Better Health
