Missouri’s Medicaid program, MO HealthNet, provides healthcare services to residents who meet specific income and eligibility requirements. This article clarifies the rules, eligibility criteria, and administrative processes associated with physical therapy coverage for adult participants enrolled in MO HealthNet.
Coverage Status and Adult Eligibility
Yes, Missouri Medicaid does cover physical therapy services for adults, though coverage is limited compared to the benefits provided to children. The Missouri Department of Social Services (DSS) provides MO HealthNet coverage to several adult categories, including those who are aged, blind, or disabled (ABD), as well as expansion adults under the Affordable Care Act (ACA) guidelines. The specific eligibility group a person belongs to determines the exact nature and extent of their physical therapy benefit.
This coverage is generally considered an optional benefit under federal Medicaid guidelines, but Missouri has chosen to include it for certain adult populations. Coverage for physical therapy falls under the broader umbrella of rehabilitative services intended to correct or limit a disability. Therefore, an adult must first be determined eligible for MO HealthNet through an approved pathway before any therapy benefits can apply.
Scope of Covered Physical Therapy Services
MO HealthNet covers physical therapy services that are medically necessary and contribute to the patient’s recovery or rehabilitation from an illness or injury. The primary focus of covered services is on rehabilitative or restorative care, which aims to improve the patient’s functional status. Examples include post-surgical rehabilitation, therapy following a stroke, or treatment for an acute injury that limits mobility or function. The services must be part of an active written plan of care established by a physician.
Physical therapy is covered in various settings, including outpatient clinics, home health, and inpatient facilities like skilled nursing facilities. In contrast to restorative care, maintenance therapy—which is designed to prevent deterioration or maintain a current level of function—is generally not covered unless a skilled therapist is required to safely and effectively deliver the treatment. The distinction between restorative and maintenance therapy is often based on whether the patient’s condition is expected to improve.
Coverage Limits and Authorization Requirements
Physical therapy coverage for adult MO HealthNet participants is subject to quantitative limits, which vary depending on the specific eligibility group. For adults covered under the Adult Expansion group, the combination of all habilitative skilled therapy services, including physical, occupational, and speech therapy, is limited to a total of 20 visits per rolling year. This annual visit cap includes services from all MO HealthNet providers, meaning a patient cannot receive 20 physical therapy visits plus 20 occupational therapy visits.
Prior Authorization (PA) is a key administrative requirement that often dictates whether therapy services will be reimbursed. While prior authorization is not required for the initial 20 visits for the adult expansion group, other MO HealthNet groups or services may have different requirements. When a PA is necessary, the provider performing the service must submit the request, including sufficient documentation to establish medical necessity. An approved PA confirms the medical necessity of the service but does not guarantee payment, as the participant must also be eligible on the date of service.
For beneficiaries enrolled in a Managed Care Organization (MCO), the MCO’s specific rules for prior authorization may differ from the fee-for-service program. MCOs have the flexibility to determine which services require prior authorization, though their policies must still adhere to the basic coverage and limitation policies set by the MO HealthNet Division. Providers should contact the specific MCO to understand their exact pre-certification or prior authorization requirements.