MO HealthNet January 2026 Newsletter: Important Changes for Providers

Missouri Department of Social Services sent this bulletin at 01/02/2026 11:05 AM CST

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Welcome!

Thanks for reading the MO HealthNet Provider Newsletter. Our goal is to keep the lines of communication open between the MO HealthNet Division (MHD) and healthcare providers. We're glad you're here!

What's New?

The State of Missouri has been awarded more than $216 million in funding for the first year of the Rural Health Transformation Program.

The Rural Health Transformation Program emphasizes collaboration among hospitals, clinics, community-based organizations, and local leaders to develop sustainable solutions tailored to the unique needs of Missouri’s rural areas.

Read the full press release: Governor Kehoe Secures More Than $216 Million to Strengthen Rural Healthcare in Missouri

For more information on Missouri's RHT plan, please visit DSS's website.

📣 Leadership Update for Providers

Josh Moore, PharmD, Appointed State Medicaid Director

Governor Mike Kehoe and the Missouri Department of Social Services (DSS) announced the appointment of Josh Moore, PharmD, as Director of the MO HealthNet Division (MHD), effective immediately.

🔍 What this means for providers

Leadership continuity: Moore previously served as MHD Director of Pharmacy (since 2019)
Deep familiarity with provider reimbursement, policy, and program operations
Experience overseeing both managed care and Fee-for-Service delivery systems
Ongoing focus on access, quality, fiscal stewardship, and program stability

As State Medicaid Director, Moore will oversee key areas that directly affect providers, including:

Policy development and implementation
Provider enrollment and reimbursement
Managed care and Fee-for-Service program operations
Compliance with federal Medicaid requirements

Josh Moore succeeds Todd Richardson, who resigned as MHD Director in October 2025.

👉 Read the full press release: Governor Mike Kehoe and Missouri Department of Social Services announce Josh Moore, PharmD, as State Medicaid Director

⚡ Spend Down Got Easier – Now It’s Faster!

The Family Support Division (FSD) has introduced automated spend-down processing, allowing activation in as little as one business day for charges submitted via the online MO HealthNet Spend Down Provider form.

Benefits:

System verifies submissions overnight
Coverage activates once spend-down is met
Participants can access services and prescriptions faster
Providers can begin billing immediately

For details, see the Hot Tip: Spend Down Got Easier – Now It’s Faster!

🏠 Home and Community Based Services (HCBS) Providers: Checking Remaining Prior Authorization (PA) Units

HCBS is a program designed to help eligible individuals (primarily older adults and people with disabilities) receive care and support in their own homes or communities rather than in institutional settings like nursing homes.

You can verify how many units a participant has left on their prior authorization (PA) in the DHSS Fusion system.

If you need help navigating the new system, contact 📧 HCBS.Systems@health.mo.gov

💉 Vaccines for Children (VFC) Updates

VFC is a federally funded program that provides free vaccines to eligible children, ensuring that cost is not a barrier to immunization.

The VFC Program has expanded to include new vaccines to prevent respiratory syncytial virus (RSV) and meningococcal disease for eligible children ages 0–18.

More details in Bulletin 48-27.

🖥 New webpage about Department of Social Services (DSS) Portals

A new webpage is now available to help participants manage DSS benefits.

The page includes:

Direct links to each benefits portal
Step-by-step account creation instructions
Contact information and helpful resources

A printable flyer is also available for patients. Please share this information with your eligible patients!

💊 Maximum Daily Limits for Drugs on Crossover Claims

Effective February 15, 2026

MHD will enforce maximum daily limits for drugs billed on crossover claims. Accurate National Drug Code (NDC) and quantity reporting are both required for proper manufacturer rebate invoicing. Correctly reporting both NDCs and quantities is essential and helps reduce medication costs.

For claims with a date of service on or after February 15, 2026, claims that exceed the limits will be denied. Providers are encouraged to review their billing systems and processes to ensure accurate reporting of NDC quantities.

Refer to Bulletin 48-30 for a list of the fields to update when reporting NDC and the number of NDC units.

📋MHD offers Proper Drug Billing training for additional support.

Questions? Contact:

📞 (573) 751-6963
🕗 Monday–Friday, 8:00 a.m.–5:00 p.m.
📧 MHD.PharmacyAdmin@dss.mo.gov

🗣️ Help Shape the Future of the MO HealthNet Website

MHD is committed to continuous improvement, and we want your input.

A short survey is now open to all healthcare providers to gather feedback on the organization, navigation, and overall usefulness of the MO HealthNet Website. Your feedback will help us improve how information is structured and accessed.

🕒 Time commitment: Less than 5 minutes

📋 Who should participate: All MO HealthNet healthcare providers

👉 Take the survey: MO HealthNet Overall Site Experience

Thank you for partnering with us to improve the MO HealthNet Website.

In Case You Missed It

🏥 Prescribed Pediatric Extended Care (PPEC) Program

Effective August 28, 2025, MHD began covering PPEC services. The program was developed to provide eligible children with medical complexities the opportunity to thrive socially, emotionally, and medically by receiving multidisciplinary services in a day program setting.

PPEC offers the following to eligible children:

Personal care
Skilled nursing
Occupational, physical, and speech-language therapy

👉 Full details, including participant eligibility and MO HealthNet provider enrollment information, are available in Provider Bulletin 48-19.

🩺 Diabetes Prevention Program (DPP) Service Updates

DPP is a structured, lifestyle change program to prevent or delay type 2 diabetes. The services include a variety of behavioral and nutritional interventions.

There are several updates designed to decrease administrative burden for providers and increase access to services for eligible participants.

Effective December 1, 2025

🔧 Administrative Changes to the DPP

No prior authorization needed for the first 12 months of core services
No prior authorization for the second 12 months of maintenance services

Keep in mind that referrals are still required from a licensed practitioner.

👥 Participant Eligibility Updates

Participants may now receive concurrent weight-reduction treatments, including medication
Previous exclusion criteria were removed

⏳ Continuation Criteria (second 12 months)

Participants may continue if they meet one of the following:

≥ 5% weight loss from baseline
A1C reduction of 0.2% or more
Or the prescribing provider documents complicating conditions affecting weight loss

🏅 Provider Qualifications

Updated to include all CDC Diabetes Recognition Program levels.

More information is in the Physician Manual and 13 CSR 70-25.130. A provider bulletin will be released soon. For questions about the DPP, contact Provider Communications at (833) 222-7916 or via eMOMED.

⏱ Electronic Visit Verification (️EVV) Accrued Minutes - Recap & Rule

Bulletin 48-26 prepared providers for the upcoming claim validation process. The information shared in this bulletin informed personal care service and home health care service providers of the accrued minutes process for them to continue receiving payment for accrued units once claim validation is implemented.

On January 7, 2026, MHD will soft launch claims validation. At this time, MHD will begin to match submitted claims for personal care and home health care services to visits in the EVV Aggregator Solution (EAS). Following the implementation of hard edits, claims not matching visits in EAS will be denied for payment.

For more information, refer the EVV provider page for information. For questions, contact MHD.EVV@dss.mo.gov.

📘 Provider Manual Updates

General Sections

MHD made several updates to the General Sections Manual. The information in this manual applies to all MO HealthNet Fee-For-Service (FFS) providers.

Updates include:

Changes to the Breast and Cervical Cancer Treatment (BCCT) program
Home birth information for managed care health plan members
Updates to the Spend Down Program information
Place of Service codes and descriptions

For more details, review the Updates to the MO HealthNet General Sections Manual Hot Tip.

Questions? Contact Provider Communications via eMOMED or call (833) 222-7916.

Behavioral Health Services Manual Updates

Recent changes include:

Section 1.6 – information added regarding increased limits for Psychiatric Diagnostic Evaluation for children under the age of 6
Section 1.6 – clarifying language was added in the Psychotherapy for Crisis section to allow for such services to be delivered in person or via telemedicine.
Section 1.11 – updated Biopsychosocial Treatment of Obesity language
Sections 1.15 and 1.16 language was added pertaining to Applied Behavior Analysis services
Section 1.18 – participant age was lowered to 15 for Transcranial Magnetic Stimulation (TMS) Treatment if a device cleared by the FDA for this age group is utilized
Section 1.19 – Screening for Depression and Follow-Up was added to provide a brief overview of codes G8431 and G8510 becoming active and referring to Physician Manual for additional information.
Section 1.21 – clarifying language was added to the Reimbursement section regarding coding for providers to utilize when providing behavioral health services via telemedicine for a Fee-For-Service participant who is located at a residential or inpatient Place of Service (POS).
Section 1.23 – language was edited to allow for use of POS 99 (Other Place of Service) in private spaces with public settings, such as a private room in a public library. Also, the POS table was edited to add POS 10 (Telehealth Provided in Patients Home) and to differentiate the descriptions between POS 02 and POS 10

For more details, review the new Behavioral Health Services Manual.

Medicare/Medicaid Claims Processing Manual

The following key updates were made:

Clarified Remittance Advice (RA) to be specific to Medicare RA or MHD RA
Included definition of MO HealthNet (Medicaid in Missouri)
Used over/under language for age groups
Linked the Social Security Administration (SSA) Website
Made formatting changes

For more information, review the Medicare/Medicaid Claims Processing Manual.

🦷 Dental Program Updates

Key Changes

Coverage of Current Dental Terminology (CDT) codes D9222 and D9223 covered for adults, refer to Bulletin 47-43 for more information
Annual CDT updates for 2024 and 2025
Coverage of periodic oral examinations (D0120) for participants 21 and older
Silver Diamine Fluoride (SDF) (CDT code D1354) coverage for:
- Participants 20 and younger
- Pregnant participants
- Blind participants
- Skilled Nursing Facility (SNF) residents

For additional information, review the new Dental Manual and visit the Dental page.

Did You Know?

👵 Program of All-Inclusive Care for the Elderly (PACE)

PACE provides 24/7 comprehensive health, social, recreational, and wellness services across settings (home, community, hospital, or nursing facility). The goal is to maximize each participant's potential and continued residence in the home and community by providing preventive primary care and other support.

PACE Centers offer:

Adult day care
Primary clinic
Therapeutic recreation
Restorative therapies
Socialization, personal care, and dining spaces

Participants must:

Be 55 or older
Live in a PACE service area
Be certified as needing nursing-home level of care
Be able to safely live in the community at enrollment

PACE participants must receive all Medicare and Medicaid services solely through the PACE network. Non-authorized services are not covered and are not reimbursed unless it is an emergency.

What You Need to Know: Identifying PACE Participants in eMOMED

To determine if a participant is in PACE, providers will see the following in eMOMED.

images of each PACE organization’s lock-in

For more information, visit the PACE Provider Page.

If you have questions, contact: MHD.PACE@dss.mo.gov

Education and Training

1st Quarter Training Schedule Now Available

The MHD Education & Training team has posted the first quarter schedule, including:

Program-specific webinars
New targeted webinar for Rural Health Clinics
New targeted webinar for Local Public Health Agencies

Due to continued high demand, the Eligibility and Spend Down webinar will remain a quarterly offering in the new year. This webinar in January is already full but please continue to watch the MHD Education and Training page for upcoming trainings.

Each webinar includes live Q&A. For a printable calendar to share with your staff, print the 2026 Q1 Provider Training Calendar.

Review key information provided during live webinars in the MO HealthNet Provider Overview Guide.

Questions: MHD.Education@dss.mo.gov

Provider Resources & Reminders

📣 Important Reminders for Providers — Participant Support & Communication

The MO HealthNet Participant Services Unit (PSU) shared several recurring issues that create confusion for participants. Please review the reminders below to ensure accurate guidance and reduce unnecessary call volume for participants and state staff.

📄 Claim Submission Guidance

We continue to receive calls from MO HealthNet participants who were told they must file their own claims for services they received. Participants should not be instructed to submit claims. Providers are responsible for billing MHD directly.

📞 Eligibility Questions

The Family Support Division (FSD) handles everything related to MO HealthNet eligibility and enrollment. If participants have questions or issues with their eligibility or enrollment, please direct them to the FSD Contact Us webpage.

❌ Pre-Certification, Prior Authorization, and Exception Requests

Please ensure your staff is aware of the following:

Participants do not have the ability to check the status of a submitted MO HealthNet exception request, only providers may access this information
Updates to a request for authorization or an exception must come from the provider, not the participant

For this provider information and more, review the Provider Contacts for MO HealthNet.

📝 Need to Fix or Resubmit a Claim?

Most denied claims can be reprocessed without re-keying the entire claim.

How to Retrieve and Modify a Claim in eMOMED

Open eMOMED and retrieve the original claim
Select “Copy Claim Original”
Make corrections
Resubmit for processing

This applies to most electronic and paper claims (with some exceptions).

For questions, contact Provider Communications via eMOMED or by calling (833) 222-7916.

📚 Want Training on Claims Processing?

MHD Education and Training can help! Visit Education and Training and sign up for a live webinar or contact us today!

📧 MHD.Education@dss.mo.gov

📞 573-751-6683

Beware of Phishing Emails

Missouri Medicaid Audit & Compliance (MMAC) issued an alert to all enrolled providers regarding a recent increase in cybersecurity threats targeting healthcare organizations, including MO HealthNet providers. If you receive a suspicious email claiming to be from MMAC, forward the message to MMAC.ProviderEnrollment@dss.mo.gov or call (573) 751-3399.

MHD Contact Information for Providers

📘 Need Help Finding the Right MO HealthNet Contact?

We maintain a comprehensive Provider Contact List with phone numbers and emails for the MHD units that providers interact with.

👉 Visit the Provider Contact List anytime you need support.

📞 Two Ways to Reach Provider Communications

If you have questions about claims, policy, or processes, you can contact Provider Communications using either method below:

📱 Phone

(833) 222-7916
(573) 751-2896

💬 Secure Direct Message in eMOMED

Log in to eMOMED
Select "Provider Communications Management"
Submit your inquiry through secure messaging

Need to Contact the Managed Care Health Plans?

877-236-1020, Option 4
Message Show Me Healthy Kids
Provider Website
Join the Show Me Healthy Kids Network

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