1915(c) HCBS waiver services are included in the Missouri Medicaid Program under the authority of a Home and Community-Based Waiver granted by the Centers for Medicare & Medicaid Services (CMS). Under a waiver, certain services that could not otherwise be reimbursed under Title XIX may be provided to a select group of participants, in order to provide an alternative to institutional care.
MO HealthNet covers services provided via Telemedicine when the service can be performed with the same standard of care as a face to face service.
Telemedicine services may be provided to a MO HealthNet participant, while the participant is at an originating site, and the provider is at another location (the distant site.) The originating site facility fee cannot be billed to MO HealthNet when the originating site is the participant’s home.
MO HealthNet providers billing vaccines for dual eligible participants shall bill Medicare for all vaccines. Vaccine coverage under Medicare Part B includes the pneumococcal, influenza, and Hepatitis B vaccines for individuals at high or intermediate risk and vaccines directly related to, the treatment of an injury or direct exposure to a disease or condition. Other vaccines not covered by Part B, such as but not limited to Tdap, Zoster, and Hepatitis B are covered by Medicare Part D. When a provider cannot bill the Part D plan directly, the vaccine should be dispensed at a pharmacy.
The MO HealthNet Division (MHD) reimburses providers for long-acting reversible contraception (LARC) devices for dual eligible participants even if their Medicare benefit does not cover it. The MHD currently has a Fiscal Edit in place to prevent duplicate billing of non-oral contraceptive products. Providers are responsible for checking criteria to confirm their patient’s eligibility for a LARC device prior to billing MHD.
MO HealthNet Division (MHD) will begin desk audits of providers to ensure proper billing units are used for drugs billed to MO HealthNet. Providers are responsible for proper billing of claims as outlined in Section 15 of the Pharmacy Provider Manual (http://manuals.momed.com/collections/collection_pha/print.pdf). Billing a claim with the incorrect unit of measure may result in greater compensation than entitled.
COVID-19: COVID Testing and Specimen Collection Codes – Updated
The MO HealthNet Division (MHD) continues to monitor Centers for Medicare & Medicaid Services (CMS) guidance related to COVID-19 testing and specimen collection. The tables below lists the COVID-19 testing and specimen collection procedure codes MHD currently covers as well as who can bill each code, effective dates, max units, and rates.
Effective November 1, 2021, MO HealthNet will cover at-home COVID-19 tests through the Fee-for-Service pharmacy benefit when prescribed and dispensed by MO HealthNet enrolled providers. At-home COVID-19 tests will be covered for participants who are dually eligible for Medicaid and Medicare when the test is excluded from Medicare Part D coverage.
Effective for dates of service on or after 7/1/2021, MO HealthNet will allow Hospital & Clinic providers to bill for an inhaler if the participant is diagnosed with COVID or the participant has been exposed to COVID-19, and the facility is awaiting test results.
On December 22, 2021, the FDA issued an emergency use authorization (EUA) for Pfizer’s COVID-19 treatment, Paxlovid. Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kilograms) with positive results of direct SARS-CoV-2 testing and who are at high risk for progression to severe COVID-19, including hospitalization or death.
Effective November 1, 2021, MO HealthNet will cover at-home COVID-19 tests through the Fee-for-Service Pharmacy Benefit. MO HealthNet will reimburse the lesser of the MAC rate plus a dispensing fee or the Usual & Customary submitted by the provider. At-home tests must be prescribed by a MO HealthNet provider. MO HealthNet will monitor the use of at-home tests to prevent potential waste. Below are the covered at-home tests, including the MAC price per unit.
