IM-82 September 20, 2012; IM-56 July 2, 2012
Upon receipt of a request for coverage of medical services received from a spend down participant, verify incurred medical expenses by requesting a copy of a receipt, bill, or other documentation to the participant for medical services provided.
An incurred medical expense does not have to be paid prior to being allowed to meet spend down. However, the expense must be the responsibility of the participant to pay. See Manual Section 0810.010.15.05 Allowable Medical Expenses for Spend Down.
- A receipt is a printed acknowledgment from the provider that payment has been received from the participant for medical services provided.
- A bill is a statement of liability from one party to another party following a transaction. For the purposes of determining eligibility for spend down coverage, the transaction is the medical services provided and received.
- Other documentation may be used in lieu of a bill for medical services. Documents including, but not limited to, patient ledgers, account statements, and billing summaries can be used when a bill is not available.
Example: A participant receives dialysis treatment three days a week. The dialysis provider bills third party insurance after each treatment, but payment from the third party is not received for more than 2 months after each treatment. Each month the participant may provide proof of his recent treatments along with billing summaries for prior treatments. This will enable him to meet his spend down on a more timely basis.
A receipt, bill, or other documentation must include the following details to be used as proof of incurred medical expenses:
- patient name
- date of service(s)
- type of service(s) provided
- charge for service(s) provided
- amount of third-party liability
- amount that the participant or spouse is responsible to pay
Note: An explanation of benefits (EOB) from an insurer or other third-party payer cannot be used as documentation of incurred medical expenses, unless it is used in conjunction with another form of documentation such as a receipt or bill.
The MO HealthNet (MHN) Spend Down Provider form can be used in lieu of a receipt, bill, or other documentation. The MHN Spend Down Provider form must be completed by the provider of the services, an authorized employee of the provider, or an authorized employee of an agency contracted to provide billing services for the provider. The signature on the form is an attestation from the provider that the information is accurate and verifiable in the event of a claim or an audit.
A typed signature is allowed on the MO HealthNet Spend Down Provider form only if the typed signature can be authenticated using one of the following:
- A letter on company letterhead that includes verifiable contact information. The letter must state the letter constitutes a signature on the MO HealthNet Spend Down Provider form.
- An email including a signature block that includes verifiable contact information.
Note: A typed signature is not allowed on other FSD forms. These instructions are specific to the MO HealthNet Spend Down Provider form.
Attachments providing the information requested on the form may be submitted in place of completing each column.
Example: The Department of Mental Health (DMH) customers do not receive a bill for services received through state-funded programs (see 0810.010.15.15.10 Identifying DMH Medical Services Allowable for Spend Down). Verification of medical expenses incurred by a participant receiving Community Psychiatric Rehabilitation (CPR), Community Substance Abuse and Rehabilitation (CSTAR), Targeted Case Management (TCM), or Developmental Disabilities (DD) waiver services paid by DMH using state-only funds can be provided on an invoice to DMH which must include:
- name and DCN of the MO HealthNet participant
- name of service provider
- provider type (first two digits of the provider number)
- date the service was provided
- service provided, identified in one of the four categories – CPR, CSTAR, TCM, or DD waiver. It does not have to include the specific service name or procedure code
- charge to DMH for service on the date it was provided
Within 2 days of receiving documentation of medical expenses, a Spend Down Notice must be sent to notify the participant:
- when the spend down liability was met
- when documentation of incurred medical expenses did not meet the spend down liability, and
- when the documentation of incurred medical expenses was not allowed to meet the spend down and why the documentation was insufficient
Review all available resources including the case record, third party liability resource information, prescription discount plans, and IIVE to confirm the accuracy of the documentation and request additional documentation when necessary.
Only the balance that the participant is responsible to pay is allowable to meet spend down for a month. If the amount of the third-party payment is not available, determine the amount of third-party payment, if any, before allowing any portion of the expense to meet spend down. Reduce the amount of the incurred medical expense by the amount that the third party is expected to pay.
Example: A participant submits a package tear strip for a prescription expense. A review of the case record determines that she has a prescription discount plan. She will need to provide a receipt in addition to the tear strip for the expense to be allowed toward her spend down.
Health Maintenance Organizations (HMOs), and other types of managed health care plans, usually assess a set copayment (copay) amount for services. In these types of plans, the participant is only responsible for the copay amount. When a participant has insurance coverage through a plan with set copay amounts, count only the copay amount toward the spend down; do not allow the “actual” cost of the service.
Example: A participant visits an HMO physician and the cost of the visit charged to the HMO is $80. The copay for a physician visits is $10. Only the $10 is counted toward meeting the spend down.
Medicare and other health insurance have deductibles and coinsurance amounts that the participant is personally responsible to pay.
Example: A participant visits a Medicare physician and the cost of the visit charged to Medicare is $120. The participant has met his annual deductible prior to this visit. The coinsurance charge for a physician visit is 20%. The participant is personally responsible for $24. Only the $24 is counted toward meeting the spend down.
Exception: The QMB program provides MO HealthNet payment of the Medicare premium, and coinsurance and deductibles for all Medicare covered services. Because QMB participants have coverage that pays Medicare deductibles and co-insurance, they are not personally responsible for those charges. The costs of Medicare covered services cannot be used to meet spend down for individuals receiving QMB benefits. See 0865.035.25 QMB Benefits Guide.