0810.010.00 MO HealthNet Spend Down Coverage

0810.010.20.20 Out-of-Pocket Expenses for Spend Down Cases

IM-15 February 22, 2012; IM-03 January 7, 2008

Senate Bill 577 (2007) amended RSMo 208.153 to allow a reduction in spend down for up to three months for a participant who paid a spend down invoice and then pays an eligible out-of-pocket medical expense in the same month. As of January 2008, if a MO HealthNet participant pays-in his or her invoiced spend down amount for the month and also pays eligible out-of-pocket medical expenses in the same month, the amount of the out-of-pocket medical expenses may be applied to reduce the amount owed on unpaid invoices for up to the next three months from the date of the expense. If the out-of-pocket expense exceeds the total of three month’s invoices, or if the documentation of the paid out-of-pocket expense is not received in time to apply it to the three month period following the date of the expense, the participant may not receive the benefit of the out-of-pocket expense reduction.

NOTE: When discussing PAID-IN spend down and out-of-pocket expenses with participants, explain that it is to the participant’s advantage to submit documentation of the paid expense in the same month the service is received and paid.

When a participant provides documentation that they have paid out-of-pocket medical expenses, within two (2) business days from receipt of documentation the eligibility specialist must view the MO HEALTHNET DIVISION PREMIUM INQUIRY SCREEN (MPNI) to verify the participant paid-in their spend down for the month for which bills for out-of-pocket medical expenses are submitted and determine if the payment was for an eligible medical expense.

ELIGIBLE OUT-OF-POCKET EXPENSE

When it is verified that the spend down was paid-in and there was an eligible paid medical expense:

  1. The eligibility specialist must:
    • Complete the Out of pocket Expenses form (IM-29OPE) noting Yes for eligible expense, and make one copy (If expenses are documented for more than one month, complete separate forms for each month.)
    • Scan the completed IM-29OPE and supporting documentation, and send to the eligibility specialist (ES) supervisor
  2. The ES supervisor will:
    • Review the IM-29OPE and supporting documentation
    • Upon approval forward it to the regional policy liaison
  3. The regional policy liaison will:
    • Enter the information on the MSPO screen,
    • Notify the eligibility specialist and ES supervisor that the entries have been made
    • Email MHD contacts to ensure that the paid out-of-pocket expenses are applied timely and correctly to the MHD invoicing system
  4. When notification is received from the regional policy liaison, the eligibility specialist will mail the IM-29OPE to the participant and file one copy in the IM case record.

The day following the entry on the MSPO screen, invoices affected will display as spend down met with “bills” in the “method” field on the MO HEALTHNET DIVISION spend down COVERAGE INQUIRY (MSPI) screen. In addition, the DIVISION OF MEDICAL SERVICES OUT-OF-POCKET EXPENSE HISTORY (MSPH) screen will show the invoices that the eligible charges entered were applied to and the amounts applied to the invoice.

NOTE: Out-of-pocket expenses can only be applied when a participant has PAID IN their spend down invoice, then pays for a medical service out-of-pocket in the same month. They cannot be applied after a participant has met their spend down with incurred or paid bills.

Participants may continue to receive invoices for the months that expenses have been applied, depending on the when the information is received by the eligibility specialist and the regional policy liaison enters it into MSPO, and when the MHD invoicing system applies the out-of-pocket expense. Due to the process to adjust an invoice, staff must scan and send the documentation along with the IM-29OPE to the supervisor and the supervisor must forward the completed forms and documentation to the regional policy liaison the same day the IM-29OPE is completed.

Participants who submit out-of-pocket expenses and have questions regarding their invoices and necessary payments should be directed to call MHD Premium Collections at 877-888-2811.

NOTE: If a participant pays the full invoice amount after an eligible out-of-pocket expense was applied, the out-of-pocket expense will be manually moved by MHD to the invoiced amount for the next month. MHD will not issue a refund to the participant. If a participant continues to pay full invoice amounts, MHD will only manually move out-of-pocket expenses for a maximum of 6 months.

EXAMPLE: Mr. Avery pays his monthly spend down invoice of $100 by check each month. He paid his September spend down on August 28, 2007. Mr. Avery had dental expenses of $250 on September 2, 2007. Mr. Avery reported that he paid out-of pocket dental expenses for September to his eligibility specialist on September 5, 2007, and provided his bill from the dentist office showing that he paid for his services. Mr. Avery has not sent in his payment for the invoice for the month of October. The eligibility specialist completes the Out-of Pocket Expense Form (IM-29OPE) to show the expense applied for the following 3 months, October, November, and December.

Depending on the date the expense documentation is received and entered, it may be applied $100 for October, $100 for November and $50 for December, leaving $50 of the $100 spend down to be invoiced for December. Unless additional out-of-pocket expenses are entered in November and December, or a budget adjustment is entered or MHD manually moves out-of-pocket expenses, the January invoice will return to the full $100 spend down amount.

EXAMPLE: Mr. Finestein pays his monthly spend down invoice of $30 by check each month. The MO HealthNet Division received his check for December spend down on November 28, 2007. Mr. Finestein had dental expenses of $100 on December 14, 2007, and provided his eligibility specialist a copy of the bill showing that he paid for the services. The eligibility specialist completes the Out-of Pocket Expense Form (IM-29OPE) reflecting December PAID expenses applied for the following 3 months, January, February, and March.

As three months is the maximum number of months the paid expense can be applied and his spend down amount is $30 per month, depending on the date the expense documentation is received and entered, the out-of-pocket expense may be applied as follows: $30 to January, $30 to February and $30 to March. The $10 remaining from the $100 paid on December 14, 2011 cannot be applied to an invoice as in doing so it would exceed the three month period following the month of paid out-of-pocket expenses.

Automatic Withdrawal Of Spend Down Premiums

Participants who have automatic withdrawal (Electronic Funds Transfer (EFT)) of their spend down premium payment will continue to have the full invoiced amount deducted from their account less any out-of-pocket expenses entered on MSPO for that invoiced month. If the participant pays an eligible medical expense in the same month that their spend down payment was automatically withdrawn, the above process for entering out-of-pocket expenses should be followed. The next month’s invoiced amount will adjust and only automatically withdraw the adjusted amount after the eligible out-of-pocket expenses have been applied. MHD will not issue refunds to the participant.

Couple Spend Down Cases

A spouse’s expenses can be used to meet spend down; therefore, a spouse’s out-of-pocket expenses can also be used to reduce the next 3 invoices. However, MSPO entries to reduce the next 3 invoices can only be entered under the head of household that the invoice was issued to and displayed as paid on MPNI.

INELIGIBLE OUT-OF-POCKET EXPENSE

When it is determined the participant did not did not pay for an eligible medical expense the eligibility specialist will:

  • Complete the IM-29OPE, noting No to eligible expense and the reason not eligible. (If expenses are provided for more than one month, complete separate forms for each month.) Make one copy of the form.
  • Mail the original to the participant and file one copy in the IM case record.

Do not send the IM-29OPE for ineligible medical expenses to the ES supervisor or the regional policy liaison.

EXAMPLE: Mrs. Moore paid her September 2011 spend down invoice of $158. On January 5, 2012, Mrs. Moore provided some documentation to the eligibility specialist that she wanted to apply to out-of-pocket expenses. The documentation provided was an explanation of benefits from the participant’s Part D plan dated 9/2/2011, which stated what the “plan paid” and what you paid”, in addition to “other payments made by programs or organizations.” There was no accompanying verification from the pharmacy used to indicate that participant had actually paid the co-pays.

This is not an eligible out-of-pocket request for two reasons which the eligibility specialist recorded in the appropriate section of the IM-29SPDN:

  • September dates of service could offset October, November and December invoices. The documentation wasn’t received until January 5, 2012 therefore it could not be applied to October, November and December invoices, and
  • The documentation provided did not verify the participant had actually paid the pharmacy co-pays.

EXAMPLE: Mrs. Plano paid her October 2011 spend down invoice of $136. On January 06, 2012, Mrs. Plano provided some documentation to the eligibility specialist that she wanted to apply to out-of-pocket expenses. The documentation provided was a statement from her doctor’s office which indicated a balance due of $21.19. The itemization indicated the $21.19 expense was from a date of service 05/13/11. There was additional itemization reflecting charges of $95 on 10/14/11, an adjustment of $27.95, and a payment of $67.05.

These are not eligible out-of-pocket expenses for the following reasons, which the eligibility specialist records in the appropriate section of two separate IM-29OPE forms. Two IM-29OPE forms are required as it is two different services dates in different 3 month periods.

  • A date of service of May 13, 2011, could offset June, July and August invoices. As these months have passed, the out-of-pocket expense cannot be applied to offset June, July, or August invoices.
  • A date of service of October 14, 2011, could offset November, December, and January. Although documentation for the date of service of October 14, 2011 could be used to offset January invoice, it is unclear what the adjustment was for and who paid the $67.05 and what amount if any Mrs. Plano paid.