IM-148 September 27, 2019; IM-88 November 2, 2012; IM-08 January 24, 2012; IM-53 September 8, 2011; IM-35 June 14, 2011; IM-127 August 31, 2000
13 CSR 40-2.395 defines the Spend Down Program as “…a program created for persons…who have income that exceeds the Medicaid qualification limits. Such individuals may qualify for Medicaid benefits when they spend down their income that exceeds the Medicaid eligibility limit. Medicaid coverage begins when the individual’s incurred medical expenses equal the monthly spend down requirement.”
Incurred medical expenses are defined as the expenses incurred by the participant or spouse for necessary medical and remedial services that are recognized under state law and not subject to payment by a third party, unless the third party is a public program of a state or political subdivision of a state.
Income of both spouses is counted to determine the spend down amount if both spouses are in the home. Refer to 0805.015.05 Persons Whose Income and Needs Are Considered. Consider the medical expenses of both spouses, even if only one is eligible for MO HealthNet. Evaluate medical expenses to determine if they can be counted toward spend down. Allow only the portion of the expense that the individual or his/her spouse is responsible to pay.
13 CSR 70-3.100(7)(D) describes how to identify the date of service for several different claim types. The date a medical expense is incurred (also known as the date of service) is the date the individual receives the service, not the date of the bill or the date a bill is paid.
For services in which a medical device or item is received, such as dentures, hearing aids, and eyeglasses, the date of service is the date of delivery or placement of the device or item. The date of service for items dispensed by a pharmacy is the date each item is filled.
Some services, such as rental of durable medical equipment (DME), may be billed on a monthly basis, without consideration of how many days the equipment is actually in use. For this type of expense, determine the third-party liability and allow the participant liability as of the date it is billed.
EXAMPLE: Mr. X does not have Medicare or other health insurance. Mr. X has a spend down of $100.00. The pharmacy bills him for the use of an oxygen machine on the first of the month for $150.00. The expense of $150.00 exceeds the spend down liability of $100.00. Mr. X meets his spend down on the 1st day of the month.
EXAMPLE: Mr. X has a spend down of $100. In order to recover from surgery, Mr. X receives a rental wheelchair which he uses for 16 days before returning it. The equipment supplier only rents wheelchairs on a monthly basis, for $30 per month. Mr. X can apply the entire $30 toward his spend down for the wheelchair rental.
Other services, such as personal care and similar in-home services, may be billed on a daily basis. Verify the daily charge and the days of the month the participant receives the service. Allow the daily charge that is the participant’s responsibility, for each day the service is received.
EXAMPLE: Mr. X does not have Medicare or other health insurance. His spend down is $100. He receives in-home services on a daily basis. He provides a patient ledger on the 7th of the month that shows his daily charges so far for this month. On the first, second, third, and fourth days of this month he received $28 of in-home services each day. He met his spend down on the fourth day with a liability of $22.
The types of medical expenses that can be counted to meet spend down include:
- all types of medical expenses covered by Title XIX per RSMo 208.152
- all prescribed drugs and dental care
- prescribed, over-the-counter nutritional supplements, nutrition replacements, dietary supplements
- health care services rendered in the home including the cost of physical, occupational and speech therapy; services of home health aides; medical supplies such as surgical dressings, splints, casts, syringes, oxygen, aces, catheters, colostomy bags, and other similar medical supplies; and rental DME such as oxygen tents, iron lungs, hospital beds, and wheelchairs
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- Permanent additions or changes to the structure of a building, home, or dwelling are not allowable expenses for spend down.
- personal care services not currently provided by other federally-funded programs (i.e. Title XIX)
- medically related homemaker/chore services
- medically related adult day health care or adult day treatment, expenses associated with personal care services; medically related homemaker/chore services, or adult day health care services
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- If applicable, contact the Department of Health and Senior Services staff to verify the assessed medical need for homemaker/chore services and/or adult day health care; and/or request that the participant provide a medical statement from the attending physician, which outlines the need for medically-related homemaker/chore services and/or adult day health care. Personal care services, medically related homemaker/chore services, or adult day health care services will not include:
- services provided by family members, regardless of whether or not they live with the participant. Family members are defined as blood relatives in the first and second degree. This includes spouse, child, parent, grandchild, grandparent, brother and sister.
- services currently being provided and paid for through other federally-funded programs, i.e. all expenses currently being paid through Title XX funds, or other third-party coverage, and/or
- non-medically-related homemaker/chore or adult daycare programs.
- If applicable, contact the Department of Health and Senior Services staff to verify the assessed medical need for homemaker/chore services and/or adult day health care; and/or request that the participant provide a medical statement from the attending physician, which outlines the need for medically-related homemaker/chore services and/or adult day health care. Personal care services, medically related homemaker/chore services, or adult day health care services will not include:
- Independent Living Waiver Services authorized by the Division of Vocational Rehabilitation through a contract with a Center for Independent Living (CIL). The waiver provides services to disabled individuals age 18 through 64. Waiver services include:
- case management
- personal care services
- environmental accessibility adaptions
- specialized medical equipment and supplies
The waiver allows for self-directed services. The participant contracts, selects, and trains the person they choose to deliver services and care. Participants may hire family members (other than a spouse) to provide waiver services. Verify participant enrollment and cost of waiver services through the appropriate CIL.
- private duty nursing services in the home
- prosthetic devices
- hearing aids
- eyeglasses (require a statement of medical necessity from the physician and optometrist to allow additional treatments and coatings for eyeglasses; must define the specific reason(s) for the medical necessity)
- services of optometrists; opticians; chiropractors; chiropodists, podiatrists, or acupuncturists
- residential and day habilitation services prescribed by a physician and authorized by the Department of Mental Health (DMH).
- Verify DMH authorization and prescription by a physician by viewing an Individual Plan of Care (IPC) or Individual Habilitation Plan (IHP) which contains the physician’s signature and DMH authorization.
- Obtain a copy of the IPC or IHP and verification of the daily rate and total cost of residential or day habilitation services from the DMH regional center case manager serving the region where the claimant resides.
NOTE: Only residential or day habilitation services are allowable. Other habilitation services are not allowed toward spend down.
- emergency ambulance services
- transportation, with the following conditions:
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- Allow only medically necessary transportation to scheduled, physician-prescribed non-elective treatments.
- Transportation to obtain medical treatment or services is allowed at the current rate of mileage reimbursement for state employees or the actual cost of the transportation, whichever is less. Changes to the mileage reimbursement rate for state employees occur on July 1st and can be found here.
- Allow transportation costs for trips to and from a pharmacy or other location to fill prescriptions. Verify the mileage claimed is for a medically related trip using the date on the bill or receipt for the medical expense. Handwritten statements are not acceptable.
- Transportation expenses are not allowed for participants with active MO HealthNet/Non-Emergency Medical Transportation (NEMT) coverage. NEMT is considered third-party liability, unless it is verified the participant was unable to obtain NEMT.
- The date of the trip is considered the date of service, not the date paid.
- The date of the trip and medical necessity must be verified and clearly documented in the case record.