MEMORANDUM

2012 Memorandums

IM-#40      05/01/12

DEPARTMENT OF SOCIAL SERVICES
FAMILY SUPPORT DIVISION
P.O. BOX 2320
JEFFERSON CITY, MISSOURI
TO:
ALL COUNTY OFFICES
FROM:
ALYSON CAMPBELL, DIRECTOR
SUBJECT:
GATEWAY TO BETTER HEALTH
MANUAL REVISION #23:
1600.000.00
1600.005.00
1600.010.00
1600.010.05
1600.010.10
1600.010.15
1600.010.015.05
1600.010.015.10
1600.010.015.15
1600.010.015.20
1600.010.20
1600.010.25
1600.010.30
1600.010.35
1600.010.40
1600.010.45
1600.015.00
1600.020.00
1600.025.00
1600.030.00

DISCUSSION:

On July 28, 2010, Missouri's request for a section 1115 demonstration project, entitled "Gateway to Better Health," was approved. This demonstration project provides financial support to specified St. Louis Health Centers.

Beginning July 1, 2012, a pilot program will be implemented to enroll low-income, uninsured individuals who are not currently eligible for Medicaid into a health care coverage model. The coverage includes Tier I and Tier II benefits for uninsured adults, age 19-64 who reside in St. Louis City or St. Louis County and who meet certain eligibility criteria. Tier I coverage benefits include preventive, family, and well care and are provided at participating primary care centers. Tier II coverage benefits includes specialty care services and are provided at St Louis Connect Care or Urgent Care Clinic.

Gateway to Better Health (GTBH) coverage is intended for those individuals ineligible for all other MO HealthNet programs. The beginning date for coverage under the Gateway to Better Health Program cannot begin prior to July 1, 2012 and ends December 31, 2013.

NOTE: If the participant is eligible for Uninsured Women's Health Services (UWHS) program or is covered under the Extended Women's Health Services (EWHS) program she is eligible to receive Gateway Coverage as well.

ELIGIBILITY CRITERIA

To qualify for GTBH Tier I the following eligibility criteria must be met:

To qualify for GTBH MO HealthNet Tier II the following eligibility criteria must be met:

The Citizenship/alien status and Social Security Number requirements are the same as for the MO HealthNet for Families (MHF) program. There are no resource limits for the Gateway to Better Health program.

PARTICIPATING HEALTH CLINICS

NEED FOR TREATMENT

"Need for treatment" (Tier II only) means that, in the opinion of the treating health professional that the individual is in need of specialty care services. These services include diagnostic services that may be necessary to determine the extent and proper course of treatment, as well as treatment itself.

Need for treatment is considered verified by the submission of a GTBH application from Connect Care.

UNINSURED

To be eligible for Gateway to Better Health an individual must be uninsured.  Health insurance is defined as insurance that minimally provides coverage for physician's services and hospitalization.  There is no penalty or waiting period for dropping insurance.

Health insurance does not have to cover all medical conditions (such as pre-existing conditions) to cause ineligibility.

The term "health insurance" does not include short-term, accident, fixed indemnity, limited benefit or credit insurance, coverage issued as a supplement to liability insurance, insurance arising out of a worker's compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self insurance.

An individual who has exceeded a lifetime maximum for all benefits under their health plan are considered uninsured. The applicant must provide documentation they have reached their lifetime maximum for all benefits.

APPLICATION AND ELIGIBILITY PROCEDURES FOR GTBH

The application form for GTBH is the IM-1GW (copy attached).  The participating health clinic will assist the participant in filling out the IM-1GW application and return it to the St. Louis City, Chouteau office.  Individuals may only apply at a participating health clinic. All applications will be processed at the Chouteau office.

The approval notice for GTBH is the GW460.

GTBH cases are not subject to the annual reinvestigation.  If a participant is determined ineligible on any factor due to an interim contact, normal closing procedures will be followed.  These include ex-parte procedures.

GATEWAY TO BETTER HEALTH COVERAGE

Coverage under GTBH begins on the 1st day of the month of application, if all eligibility requirements are met.  There is no prior quarter coverage. No coverage can begin prior to July 1, 2012.

Tier I Benefits: Preventative; well care; dental (diagnostic, periodontal, preventive, prosthodontics and the removal of erupted teeth); internal and family practice medicine; gynecology; generic prescriptions dispensed at primary care clinics.

Tier II Benefits: Cardiology; DME (on a limited basis); endocrinology; ENT; gastroenterology; neurology; oncology, radiation therapy, rheumatology, laboratory/pathology services; ophthalmology; orthopedics; outpatient surgery; physical, occupational or speech therapy (on a limited basis); podiatry; pulmonology; radiology (x-ray, MRI, PET/CT scans); renal; urology; urgent care; transportation; and generic prescriptions dispensed at an urgent care or specialty care clinic.

NOTE: Participants who qualify for GTBH Tier I can receive both Tier I and Tier II benefits.  Participants who qualify for GTBH Tier II only receive Tier II benefits.

MEDICAID CATEGORY HISTORY SCREEN

The Medicaid Category and Medicaid Code for the Gateway to Better Health coverage groups will display on the Medicaid Category History (MEDHIST or FM4L) screen as follows:

Description Medicaid Category ME Cd
Tier I Group (below 133% FPL) TIER1 91
Tier II Group (below 133% FPL) TIER2 92
Tier II Group (134% to 200% FPL) TIER2 93

NECESSARY ACTION:

ATTACHMENTS:

AB

2012 Memorandums