Home and Community Based Services Manual


2.00 Appendix 1 Missouri's Medicaid Program

Revised - February 2026

Introduction

Missouri’s Medicaid program, also known as MO HealthNet, offers health care access based on income, age, health and need. Missouri Medicaid determinations are made by the Department of Social Services (DSS), Family Support Division (FSD). Complete information on eligibility and how to apply for benefits can be found at Apply for MO HealthNet. 

Purpose

This policy explains the types of Medicaid that cover Home and Community Based Services (HCBS). The participant must have active Medicaid Benefits and a Medicaid Eligibility (ME) code that covers HCBS. Each type of Medicaid determines which services the participant may be eligible for. 

Medicaid's Standard Eligibility Requirements

Medicaid benefits are available to persons who:

  • Make less than the annual income limit for household size
  • Live in Missouri and are a United States citizen (or qualified non-citizen)
  • Have (or apply for) a Social Security Number (SSN); 
  • Are 65 years of age or older (19-64 for Expansion Adults), or 
  • Disabled (determined to be permanently and totally disabled), meaning you are unable to be gainfully and substantially employed for one or more years due to physical or mental incapacity or
  • Have applied for other benefits (ex., social security)
  • Are legally blind (vision less than 5/200); and
  • Do not own resources that exceed the resource limit:
    • Married couples with resources exceeding the maximum may qualify for a Division of Assets. This process sets aside a share (portion) of a married couple’s assets so that one spouse can qualify for HCB Medicaid, a Qualified Income Trust (QIT), or Nursing Facility coverage. One spouse must be eligible for an Aged and Disabled Waiver (ADW) service through HCBS, or one spouse must enter a nursing facility. 

Medicaid (non-spenddown)

Participants whose monthly income is less than the monthly income limits for their household size are considered to have Medicaid non-spenddown. Participants whose adjusted income exceeds this guideline, as determined by FSD, may be eligible for Medicaid benefits with a spenddown, and/or if age 63 or older, may be eligible for HCB Medicaid or QIT.

Medicaid (spenddown)

Participants whose income exceeds the income limit may still qualify for Medicaid if they agree to pay or “spend down” a certain amount each month, as determined by FSD.

The spenddown liability is the amount by which an individual’s or a couple's net income exceeds the non-spenddown income limits. Once FSD determines eligibility, the participant remains Medicaid eligible until a change in their situation makes them ineligible. The participant does not need to reapply each month; however, to maintain active Medicaid coverage, the spenddown must be paid each month. 

  • Participants may meet their spenddown obligation by: 
    • Paying the spenddown liability directly to the MO HealthNet Division (MHD) each month. This ensures active coverage for the entire month. A timely monthly payment gives the participant continuous Medicaid coverage; or
    • Submitting medical bills that reach the participant’s spenddown liability to the local FSD office. Active coverage begins the day the participant meets the spenddown liability and continues through the rest of that month. On the day the participant reaches their spenddown liability, MHD will only pay for medical services that exceed the spenddown amount. Individuals do not have to pay their medical expenses before being considered to have met their spenddown liability.
  • Once determined eligible for Medicaid spenddown, a participant will be “locked in” to receive Medicaid coverage.

Blind Pension

The Blind Pension (BP) program is a state funded program that aids participants who are blind and do not qualify for Supplemental Aid to the Blind (SAB) or Supplemental Security Income (SSI) benefits. Qualified recipients receive a monthly cash payment and state-funded Medicaid coverage. For additional details about the BP program: Blind and Visually Impaired Financial Assistance

Benefits are available under the BP program to persons who:

  • Are age 18 or older; 
  • Live in Missouri and are a United States citizen (or qualified non-citizen);
  • Are of good moral character and provide a blind pension moral character form;
  • Do not own resources over the resource limit for their household size. 
  • Did not give away, or transfer property for the purpose of reducing resources to below the limit;
  • Meet specific blindness criteria;
  • Do not have a sighted spouse who is able to support the participant;
  • Do not publicly solicit alms (asking for food or money); 
  • Do not hold a valid driver’s license;
  • Are not a resident of a public or medical institution;
  • Are found to be ineligible for SAB;
  • Are found ineligible to receive federal SSI benefits.

NOTE: Medical treatment for blindness may be required.

Home and Community Based (HCB) Medicaid

Medicaid rules allow higher income limits for individuals living at home who need ADW services through the HCBS program. Determining HCB Medicaid eligibility involves cooperation between FSD and DSDS or its designee. DSDS determines ADW eligibility, need, and service availability before FSD can apply the higher income level. HCB Medicaid does not provide direct cash benefits.

HCB Medicaid application requirements are:

  • 63 years of age or older; 
  • Monthly income at or below the current HCB Income Standard.
  • Meet nursing facility level of care; 
  • Eligible to be authorized for an ADW service; 

Meets the other eligibility requirements as outlined under Medicaid for the Aged, Blind and Disabled.

Qualified Income Trust (i.e., Miller Trust)

A qualifying income trust (QIT), such as the Miller Trust, enables an individual to qualify for Medicaid by reducing their countable income when a portion of their income is placed into the irrevocable trust. There are no limits on the amount of income that can be placed in the qualifying trust. The trust must specify that the state will receive any amounts remaining in the trust after the person no longer receives Medicaid benefits, up to the amount the state paid in Medicaid benefits for the owner.

  • An individual's monthly income above the HCB income standard is deposited into the irrevocable trust instead of being counted as personal income for eligibility purposes.
  • The trust must consist solely of the individual’s income, such as monthly Social Security or pension benefits (not resources), and must be used solely for the benefit of the individual.
  • A trustee manages the trust and pays for specific non-covered medically related expenses, such as
    • Remedial care received by the individual
    • Health insurance premiums other than MO Healthnet
    • Dental care, auditory care, physical therapy and rehabilitation services, etc.
    • Medically necessary improvements and/or alterations to the home
    • Transportation expenses to and from medical appointments
  • The amounts paid out of the trust may not exceed the fair market value of goods and services provided to the individual

Ticket to Work Health Assurance (TWHA

The Ticket to Work Health Assurance (TWHA) program provides Medicaid coverage, including some HCBS, for employed individuals aged 16-64 with a disability, whose income is at or below 250% of the Federal Poverty Guidelines (FPG). 

This program has two parts: the Basic Coverage Group for those permanently disabled still working, and the Medically Improved Group for those who lost coverage due to medical improvement but still meet disability criteria. Both groups provide full Medicaid benefits. 

TWHA eligibility considers: 

  • Spousal income is included in the eligibility calculation
  • Certain income is excluded, including half of the individual's wages and wages between 250% and 300% of FPG. SSI payments are not counted, and health insurance expenses are excluded.
  • A monthly premium is required if countable income is over 100% of FPG;
  • Resource limits are the same as other MO HealthNet programs. 

Once approved, coverage begins when the premium payment is received. The first invoice letter will include the premium amount for any past coverage selected through the month after approval. MHD sends a bill each month for the upcoming month’s premium. If the participant submits only part of the premium, that amount will be held until the full premium is received before coverage begins. If the premium remains unpaid for 6 months, MHD will stop sending invoices; however, the participant's eligibility will remain active, and coverage will resume once the premium is paid.

MO HealthNet Managed Care

MO HealthNet Managed Care is the program through which the state contracts with private health companies, called Managed Care Organizations (MCOs), to provide health care for low-income families, pregnant women, adults aged 19-64 without disabilities, and children under 19, or in some cases until age 21. Individuals can opt out, or they may be automatically unenrolled if they qualify for SSI, are aged, blind, disabled, or on Medicare or AIDS Waivers.

Only Managed Care participants with an ME code of E2 are eligible for HCBS Consumer Directed Services (CDS) through DSDS. All other Managed Care participants enrolled in a MO HealthNet Managed Care Health Plan are not eligible to receive HCBS through DSDS. The health plan is responsible for their personal care needs. They should be referred to their Managed Care Plan. Contact information is available under the MMIS tab in the electronic case record. 

Supplemental Nursing Care (SNC)

The Supplemental Nursing Care (SNC) program provides a monthly cash grant to cover living expenses for aged, blind, and disabled adults aged 21 or older, living in supported living facilities such as assisted living facilities (ALF) and residential care facilities (RCF). SNC will provide a monthly allowance, as well as a grant payment for your facility fees. 

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