MO HealthNet's Primary Care Health Home (PCHH) initiative strives to provide intensive care coordination and care management as well as address social determinants of health for a medically complex population. One aspect of the program includes the implementation and evaluation of the Patient Centered Medical Home (PCMH) model as a means to achieve accessible, high quality primary care; demonstrate cost-effectiveness in order to validate and support the sustainability and spread of the model, and support primary care practices by increasing available resources and improving care coordination thus improving the quality of clinician work life and patient outcomes. There are currently more than 43 participating organizations with over 208 clinic sites that make up the MO HealthNet PCHH providers.
The PCHH initiative offers comprehensive care management services for Medicaid participants who have two or more chronic health conditions including anxiety, asthma, chronic pain, COPD, depression, developmental disabilities, diabetes, heart disease, obesity, substance use disorder, and tobacco use. The program also emphasizes the integration of primary care and behavioral health care in order to achieve improved health outcomes. This website provides information regarding the development and current status of Missouri’s Primary Care Health Homes. For more information regarding the Missouri Department of Mental Health (DMH) Behavioral Health Homes, this can be accessed on the DMH website: CMHC (Behavioral) Healthcare Homes.
Health Home Resources
Implementation & Operation
- PCHH Billing Instructions for SBIRT Services
- PCHH Eligible Diagnoses – ICD-10
- PCHH Clinical Measures
- PCHH Quick Facts
- PCHH Enrollment Form | Instructions
- PCHH Transfer Form | Instructions
- PCHH Discharge Form | Instructions
- PCHH Staffing Contact Profile Form
- PCHH New Provider Orientation
- PCHH Introductory Script Guidelines
- PCHH Participant Flyer
- MO HealthNet PCHH Progress Report 2018-2019
- Member per Month Rates
- DMH Community Mental Health Center Healthcare Homes
Screening, Brief Intervention, & Referral to Treatment (SBIRT)
Community Health Worker Pilot
Patient-Centered Primary Care Medical Home
Historical Information
- Affordable Care Act Section 2703
- PCHH Provider Bulletin
- PCHH State Regulation
- State Plan Amendment (2011)
- State Plan Amendment (2016)
- State Plan Amendment (2019)
- State Plan Amendment Cover Letter (2019)
- State Plan Amendment 19-0020
- State Plan Amendment 19-0020 CMS Cover Letter
- State Plan Amendment 23-0014
- State Plan Amendment 23-0014 CMS Cover Letter
- MO HealthNet PCHH Progress Report 2014-2017
MO HealthNet News
The table below provides general information and updates that are relevant to this program page, as well as all MO HealthNet providers. To find information for all other MO HealthNet programs, or to search by date, program or keyword, visit the MO HealthNet News page. If you would like to receive updates in your inbox, subscribe to MO HealthNet News!
| Date | Volume Number | Subject | Type | Program |
|---|---|---|---|---|
| 10/10/2025 | Tobacco Prevention to Promote Health Equity | Hot Tips | All MO HealthNet Providers | |
| 10/02/2025 | 48-18 | Sunset of Direct Care Pro Provider Bulletin | Bulletins | All MO HealthNet Providers |
| 10/01/2025 | MO HealthNet Provider Newsletter - October 2025 | Newsletters | All MO HealthNet Providers | |
| 10/01/2025 | Autism Support Now ABA Panel Discussion | Hot Tips | All MO HealthNet Providers | |
| 10/01/2025 | MO HealthNet Provider Webinars Scheduled October - December 2025 | Hot Tips | All MO HealthNet Providers | |
| 09/30/2025 | Additional - 2025 Optimizing Benefits for Maternal and Infant Health Meetings | Hot Tips | All MO HealthNet Providers | |
| 09/29/2025 | MHD Offers Office Hours for Notification of Pregnancy Billing | Hot Tips | All MO HealthNet Providers | |
| 09/09/2025 | Suicide Safer Homes | Hot Tips | All MO HealthNet Providers | |
| 08/28/2025 | Invitation to Comment: Rural Health Transformation Program | Hot Tips | All MO HealthNet Providers | |
| 08/04/2025 | MO-CPAP Pediatric and Adolescent Depression Training and Office Hours | Hot Tips | All MO HealthNet Providers | |
| 07/14/2025 | Lunch & Learn Reminder: July 16th, Notification of Pregnancy | Hot Tips | All MO HealthNet Providers | |
| 07/09/2025 | 48-02 | Diagnosis Code Expansion | Bulletins | All MO HealthNet Providers |
| 07/07/2025 | Provider Training Schedule Posted, July – September 2025 | Hot Tips | All MO HealthNet Providers | |
| 07/01/2025 | 2025-3 | Provider Newsletter 3rd Quarter 2025 | Newsletters | All MO HealthNet Providers |
| 05/21/2025 | Breast and Cervical Cancer Treatment (BCCT) Expansion | Hot Tips | All MO HealthNet Providers |