0810.010.00 MO HealthNet Spend Down Coverage

IM-56 July 2, 2012

Participants may combine incurred medical expenses and partial pay-in of a MHD invoice amount to meet spend down in one of the following ways:

• submitting incurred medical expenses not subject to payment by a third party to the local Family Support Division (FSD) office and paying in the remainder of their spend down amount to the MO HealthNet Division (MHD) Premium Collections; or
• submitting a partial payment of their spend down amount to the MHD Premium Collections and submitting incurred medical expenses not subject to payment by a third party to the local Family Support Division (FSD) office.
  NOTE:  Incurred medical expenses can be carryover and/or current expenses. See Section 0810.010.15 Meeting Spend Down With Incurred Expenses.

Participant Submits Bills Prior to Submitting Payment

When a participant sends incurred expenses to the local FSD office that do not meet their spend down liability, the eligibility specialist (ES) determines the remaining spend down liability and sends the participant the Spend Down Notification (IM-29(SPDN)) form to inform the participant that they need to provide additional bills or partial pay-in to meet spend down. If they choose to mail a partial payment to the MHD Premium Collections, the participant should include the IM-29 (SPDN) Spend Down Payment Option page and their invoice, if available.

If a participant makes a partial payment for the same month that the medical expenses are incurred, spend down coverage starts from the last date of service when total expenses plus partial payment meets the spend down amount.

If there are carryover incurred expenses from the prior three months combined with partial payment, spend down coverage starts on the first date of the month coverage is selected by the participant.

Participant Submits Payment Prior to Submitting Bills

If the participant sends partial payment to the MHD Premium Collections, the partial payment is held for 60 days from the last day of the month the payment is received. MHD will notify the MO HealthNet (MHN) Program and Policy to determine if incurred medical expenses have been submitted.

Processing Partial Payments

MHD will send a notice to MO HealthNet (MHN) Program and Policy that a partial payment has been received including:

• participant’s name and DCN,
• date received,
• amount of the payment, and
• month payment should be applied if different than the month received (if known).

MHN Program and Policy corresponds with the local FSD office to determine if incurred expenses have been received and the start date of coverage.

MHN Program and Policy enters spend down liability and date in MO HEALTHNET DIVISION ADD spend down COVERAGE (MSPA) screen and updates the Method field code in MO HEALTHNET DIVISION spend down UPDATE (MSSU) screen to “O” for other, and notifies MHD to process the payment.

MHN Program and Policy notifies the local FSD office to send an IM-29(SPND) form to the participant notifying them of the date spend down was met.