FROM: REGINALD E. McELHANNON, INTERIM DIRECTOR
SUBJECT: DEDUCTING POST ELIGIBILITY MEDICAL EXPENSES FROM THE SURPLUS OF MO HEALTHNET VENDOR PARTICIPANTS
MANUAL REVISION # 85
0815.030.10.15
DISCUSSION:
Participants who receive MO HealthNet for the Aged, Blind, and Disabled (MHABD) vendor coverage may deduct certain medical expenses from the surplus amount- health insurance premiums and Post Eligibility Medical Expenses (PEME).
The Post Eligibility Medical Expense deduction allows for a participant’s surplus to be reduced to enable him/her to pay for necessary medical expenses that were incurred during the three months prior to the month of their application.
Example: Ms. Gray applies for MO HealthNet Vendor coverage on July 25, 2019. She is approved for ongoing coverage effective with the month of application. Ms. Gray is not eligible for MO HealthNet coverage during the prior quarter months. She can request that her surplus be reduced to allow her to use her current income to pay her outstanding medical bills from the prior quarter months.
PEME guidelines are discussed in MHABD Manual section 0815.030.10.15 titled Medical Deductions When Determining Surplus.
Upon receipt of a request for a surplus reduction due to Post Eligibility Medical Expenses, request a copy of the receipt or bill to verify the countable medical expense(s).
The receipt or bill must include:
- name of patient,
- date of service(s),
- type of service(s) provided,
- charge for service(s) provided,
- amount of third party liability, and
- amount that the participant is responsible to pay.
The FAMIS system is not currently programmed to deduct PEME expenses from the surplus. The expenses should be entered on the MEDEXP screen as Health Insurance (HI), with PEME listed in the description field. A detailed comment must describe the expenses and the number of months in which the surplus will be reduced to cover them.
If the surplus will be reduced for three months or less, the appropriate end-date can be entered at this time. If the surplus will be reduced for longer than three months, staff must manually track a reminder to end-date the expense in the appropriate future month. Failure to end-date the expense may result in a claim.
Example: Gray has a surplus of $100 per month. She has $1000 in Post Eligibility Medical Expenses that can be used to reduce her surplus. The $100 surplus will be reduced to zero for 10 months.
Participants who are eligible for a Post Eligibility Medical Expense reduction in their surplus must be notified using a Notice of Eligibility for Nursing Facility and Other Vendor Services (IM-62) form.
Participants who are not eligible for a Post Eligibility Medical Expense reduction in their surplus must be notified using a Notice of Case Action for Adult Medicaid and Cash Assistance (IM-33) form.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
RM/rr
