| TO: | ALL COUNTY OFFICES |
| FROM: | JANEL R. LUCK, DIRECTOR |
| SUBJECT: | MC+ MANAGED CARE EXPANSION |
DISCUSSION:
Effective January 1, 2008, the State of Missouri will introduce the MC+ Managed Care Program in Bates, Benton, Cedar, Crawford, Dallas, Hickory, Iron, Laclede, Linn, Macon, Madison, Maries, Marion, Perry, Phelps, Pike, Polk, Pulaski, Ralls, Shelby, and Vernon counties. The MC+ Managed Care Program will provide service for approximately 46,000 additional participants.
Missouri's MC+ Managed Care Program is a way for Missouri's low income and vulnerable populations to receive health care services. The goal is to improve the accessibility and quality of health care services for Missouri's MC+ Managed Care eligible population, while controlling the costs of providing that care.
Enrollment
When approved for health care services, participants who live in an MC+ Managed Care area must choose an MC+ Managed Care health plan and a Primary Care Provider (PCP). Members will receive health care services through their MC+ Managed Care health plan beginning January 1, 2008. All members of a family are encouraged to select the same MC+ Managed Care health plan. Participants will continue to receive their health care services through the MC+ Fee-For-Service delivery system through December 31, 2007.
Enrollment packets will be mailed to MC+ Fee-for-Service participants in the identified expansion counties the week of September 24, 2007. Participants can call the MC+ Managed Care Enrollment Helpline at 1-800-348-6627 for assistance when it is time to enroll in an MC+ Managed Care health plan.
The State will conduct open enrollment in the identified MC+ Managed Care expansion counties from October 15, 2007, through December 17, 2007. If the participant does not make a voluntary selection of an MC+ Managed Care health plan during open enrollment, an MC+ Managed Care health plan will be automatically assigned. Once enrolled in an MC+ Managed Care health plan, enrollees have a 90-day change period to transfer to a different MC+ Managed Care health plan for any reason. Once the 90-day change period ends, the enrollee is locked into the MC+ Managed Care health plan for one year.
After January 1, 2008, when an individual is approved for MO HealthNet benefits and is eligible for MC+ Managed Care services a new enrollment packet will be mailed to him or her. The participant will need to enroll in an MC+ Managed Care health plan within 15 calendar days of eligibility. If the participant does not choose an MC+ Managed Care health plan within 15 calendar days, an MC+ Managed Care health plan will be automatically assigned. The participant will be Fee-For-Service until they are enrolled in an MC+ Managed Care health plan either by choice or by assignment.
The MC+ Managed Care health plan will send the MC+ Managed Care member a handbook containing information about MC+ Managed Care health plan benefits.
Eligible Participants Served by MC+ Managed Care
The mandatory populations included in an MC+ Managed Care Health Plan are divided into three groups:
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Parents/Caretakers, Children, Pregnant Women, and Refugees.
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Children in the care and custody of the State of Missouri and/or those receiving Adoption Subsidy Assistance (foster children, children in juvenile court or DYS custody, children adopted through the state receiving medical benefits).
- Children eligible under the State Children's Health Insurance Program (SCHIP).
Individuals Whose MC+ Managed Care Coverage is Optional
- Individuals who receive Supplemental Security Income (SSI), meet the medical definition for SSI, or are eligible for adoption subsidy benefits may choose not to enroll or voluntarily disenroll from the MC+ Managed Care Program at anytime.
Individuals Not Eligible for MC+ Managed Care
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Aged, blind, and disabled Medical Assistance participants will not be covered by MC+ Managed Care.
- Participants covered by BOTH Medicare and MO HealthNet benefits will not be covered by MC+ Managed Care.
MC+ Managed Care Benefits
Once enrolled in an MC+ Managed Care health plan, the MC+ Managed Care member will receive an MC+ Managed Care health plan identification card. The MC+ Managed Care member will receive the following health care services through his or her MC+ Managed Care health plan:
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Primary care and clinic services
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Preventive care, including
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Well checks
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Mammograms
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Cancer screenings
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Family planning services
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Maternity services
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Inpatient and outpatient hospital services
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Mental health services (children in Alternative Care or those who get Adoption Subsidy get their mental health services in MC+ Fee-For-Service)
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Emergency services
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Durable medical equipment such as oxygen and wheelchairs
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Transportation (some children do not get transportation due to their eligibility group)
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One eye exam every 2 years and one pair of eyeglasses after cataract surgery
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24-hour access by phone
- Healthy Children and Youth (HCY) services for those under age 21
Pharmacy Benefits
Pharmacy benefits are part of MC+ Managed Care, depending on the MC+ Managed Care health plan the MC+ Managed Care member chooses. MC+ Managed Care members who choose Children's Mercy Family Health Partners will get their pharmacy benefits from MC+ Fee-For-Service and must use their red MC+ card to obtain pharmacy benefits. MC+ Managed Care members enrolled in the other MC+ Managed Care health plans must use their MC+ Managed Care health plan identification card for pharmacy benefits.
MC+ Fee-For-Service
Some benefits and services will continue to be received through MC+ Fee-For-Service even when the participant is enrolled in an MC+ Managed Care health plan. The participant will receive the following health care services through MC+ Fee-For-Service:
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Therapy services for children in a school Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP)
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Visits by a health worker to see if lead is in the participant's home
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Bone marrow and organ transplants
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SAFE/CARE examinations for abused children
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Community psychiatric rehabilitation, a special program run by the Missouri Department of Mental Health for seriously emotionally disturbed individuals
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Drug and alcohol treatment from a Comprehensive Substance Treatment and Rehabilitation (C-STAR) provider
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Targeted case management for mental health services
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Abortion (termination of a pregnancy resulting from rape, incest, or when needed to save the mother's life)
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Pregnant women over age 21 get most dental services in MC+ Fee-For-Service
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Eye glasses for pregnant women
- Protease Inhibitors (drugs for individuals with HIV/AIDS).
Important Facts About MC+ Managed Care
Once MC+ Managed Care members choose an MC+ Managed Care health plan, they will get a confirmation letter in the mail telling them when their services will begin with the MC+ Managed Care health plan. They must also choose a Primary Care Provider (PCP). The PCP may be a doctor, nurse practitioner, or a clinic in their MC+ Managed Care health plan. After choosing a PCP, MC+ Managed care members must call their PCPs when in need of health care services unless it is an emergency. In the event of an emergency, the MC+ Managed Care member should go to the nearest emergency room or call 911.
If the MC+ Managed Care member needs help selecting a PCP, refer the MC+ Managed Care member to the MC+ Managed Care Enrollment Helpline at 1-800-348-6627. A list of Primary Care Providers is available online at www.mcpluspcp.com.
MC+ Consumer Advocacy Project
MC+ Consumer Advocacy Project is an ombudsman serving the MC+ Managed Care members in the Western and Eastern Regions. An ombudsman is a problem-solver who can advise and advocate for the MC+ Managed Care participant. MC+ Managed Care members can contact the MC+ Consumer Advocacy Project for help if:
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They need help understanding their rights and benefits under MC+ Managed Care
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They feel their rights to health care are being denied
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They are not able to solve the problem by talking to a nurse, doctor, or their MC+ Managed Care health plan
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They need to talk to someone outside of their MC+ Managed Care health plan
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They are not sure how to make a grievance or file an appeal
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They want an advocate when appealing a decision by their MC+ Managed Care health plan
- They need an advocate when appealing a decision by the State.
MC+ Consumer Advocacy Project help is available to the participant at no cost by calling or writing:
MC+ Consumer Advocacy Project - Western Region
MC+ Consumer Advocacy Project
1125 Grand Blvd, Suite 1900
Kansas City, MO 64106
Phone 1-800-892-2943
MC+ Consumer Advocacy Project - Eastern Region
MC+ Consumer Advocacy Project
Legal Services of Eastern Missouri
4232 Forest Park Avenue
St. Louis, MO 63108
Phone 1-800-444-0514
Coverage Begin Date
MC+ Managed Care coverage for participants in the identified expansion counties will be effective January 1, 2008.
MC+ Managed Care Regions
The new MC+ Managed Care counties will be included in the following MC+ Managed Care Regions:
Eastern Region MC+ Managed Care Health Plans (Eastern Region Expansion Counties: Crawford, Iron, Madison, Perry, and Pike.)
Mercy CarePlus
10123 Corporate Square Drive
St. Louis, MO 63132
Phone: 314-432-9300 or 800-875-0679
http://www.mercycareplus.com/
Harmony Health Plan
23 Public Square
Suite 400
Belleville, IL 62220
Phone: 866-822-1340
http://www.harmonyhpm.com/
HealthCare USA
10 S. Broadway
Suite 1200
St. Louis, MO 63102
Phone: 800-566-6444
http://www.chchcusa.com/
Central Region MC+ Managed Care Health Plans (Central Region Expansion Counties: Benton, Dallas, Hickory, Laclede, Linn, Macon, Maries, Marion, Phelps, Pulaski, Ralls, and Shelby)
HealthCare USA
10 S. Broadway
Suite 1200
St. Louis, MO 63102
Phone: 800-566-6444
http://www.chchcusa.com/
Mercy CarePlus
10123 Corporate Square Drive
St. Louis, MO 63132
Phone: 314-432-9300 or 800-875-0679
http://www.mercycareplus.com/
Missouri Care
2404 Forum Blvd.
Columbia, MO 65203
Phone: 800-322-6027
http://www.missouricare.com/
Western Region MC+ Managed Care Health Plans (Western Region Expansion Counties: Bates, Cedar, Polk, and Vernon)
Children's Mercy Family Health Partners
215 W. Pershing Road, 6th Floor
P.O. Box 411806
Kansas City, MO 64108
Phone: 800-347-9363 http://www.fhp.org/providers_mo.asp
HealthCare USA
10 S. Broadway
Suite 1200
St. Louis, MO 63102
Phone: 800-566-6444
http://www.chchcusa.com/
Mercy CarePlus
10123 Corporate Square Drive
St. Louis, MO 63132
Phone: 314-432-9300 or 800-875-0679
http://www.mercycareplus.com/
NOTE: Blue-Advantage Plus of Kansas City will not serve MC+ Managed Care members in the Western Region expansion counties. Blue-Advantage Plus of Kansas City will continue to serve MC+ Managed Care members in the nine original Western Region counties.
What to Expect in Expansion Counties
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Eligible participants will receive a mailing from Policy Studies, Inc., the MC+ Managed Care Enrollment Broker, letting them know they will need to sign up for MC+ Managed Care by enrolling in one of the MC+ Managed Care health plans available in their region (see regional lists above). Open enrollment is October 15, 2007, through December 17, 2007.
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Participants can call the MC+ Managed Care Enrollment Helpline at 1-800-348-6627 for assistance when it is time to enroll in an MC+ Managed Care health plan.
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Participants can enroll online, over the phone, or through the mail for their MC+ Managed Care health plan and primary care provider. FSD staff should refer the calls to the MC+ Managed Care Enrollment Helpline at 1-800-348-6627 for questions they cannot answer.
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After enrollment, MC+ Managed Care members will receive a handbook and printed information about their specific MC+ Managed Care health plan in the mail, along with their MC+ Managed Care health plan identification card. This card will be needed at point of service delivery along with their red MC+ card.
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If a participant fails to enroll during the open enrollment period he or she WILL BE AUTOMATICALLY ENROLLED IN AN MC+ MANAGED CARE HEALTH PLAN. After enrollment, the participant will receive a handbook and printed information about the specific MC+ Managed Care health plan in which he or she was enrolled. The participant will also receive an MC+ Managed Care health plan identification card, which will be needed at point of service delivery along with his or her red MC+ card.
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Once participants are enrolled in an MC+ Managed Care health plan they have one 90 day period during which they may choose another MC+ Managed Care health plan. After that they must stay in that MC+ Managed Care health plan for the remainder of the twelve month period.
- Annually MC+ Managed Care members will have the opportunity to re-enroll in their current MC+ Managed Care health plan or choose another MC+ Managed Care health plan for the following year.
Additional Information about MC + Managed Care
For additional information about MC+ Managed Care, go to the MO HealthNet Division MC+ Home Page at:
https://dss.mo.gov/mhd/mc/index.htm
NECESSARY ACTION:
- Review this memorandum with all appropriate staff.
- Review websites for additional information.
- Inform MC+ Managed Care mandatory participants about MC+ Managed Care as you see them, and refer them to the resources provided in this memorandum for additional information or help in enrolling in an MC+ Managed Care health plan.