MO HealthNet for the Aged, Blind, and Disabled (MHABD) Manual – Table of Contents

0810.010.15.15.05 Allowable Third Party Payment from State Funded Programs

IM-#27, March 16, 2012

The Department of Mental Health (DMH) and the Department of Health and Senior Services (DHSS) administer programs that pay spend down participant’s expenses until the participant’s monthly spend down liability is met. After the participant’s liability is met, the providers directly bill MO HealthNet Division instead of the DMH or DHSS.

DMH: The DMH has three Divisions:

  • Division of Developmental Disabilities (DD),
  • Division of Comprehensive Psychiatric Services (CPS), and
  • Division of Alcohol and Drug Abuse (ADA).

Each division operates programs for eligible consumers that provide services through contracted providers. The DMH determines eligibility for these programs.

Division of DD administers five Medicaid Home and Community Based (HCB) Waiver programs for individuals with developmental disabilities under the Social Security Act in 1915(c). The five waivers are the:

Under these waivers, the state provides home and community-based services through Medicaid.

The Division of DD also administers Targeted Case Management (TCM) for Individuals with Developmental Disabilities. TCM is provided by DMH employees, employees of County Boards for Developmental Disabilities (a.k.a. “SB 40” Boards), and employees of other local organizations under contract with the DMH to provide TCM.

Medicaid Home and Community Based (HCB) Waiver services and TCM are not covered by Medicare or other third party insurance.

The Division of CPS administers Community Psychiatric Rehabilitation (CPR), which provides evaluations, crisis intervention, community support, medication management, and psychosocial rehabilitation to persons with severe, disabling mental illnesses. Division of CPS also provides Targeted Case Management (TCM) for adults with serious mental illness (SMI) and children with a severe emotional disturbance (SED).

CPR, CSTAR, and TCM services are not covered by Medicare or other third party insurance.

NOTE: The amount the provider charges for the services administered by the DMH are allowable incurred expenses to be used to meet the participant’s spend down.

DHSS: The DHSS Division of Senior and Disability Services (DSDS) administers the Non-Medicaid Eligible (NME) Personal Care Assistance (Consumer-Directed Model) (CDS) program. NME CDS are provided to persons with a physical disability as an alternative to nursing facility placement. During an assessment, the participant and the Bureau of Home and Community Services (HCS) staff mutually identify unmet needs and determine what services are necessary to meet those needs. NME CDS is provided through the Medicaid State Plan (MSP). The DHSS approves the participant for NME CDS units of care which are included in the care plan established through the DHSS.

The DHSS provides financial assistance for NME CDS through eligible providers, subject to appropriations. All participants of the program must meet the NME CDS requirements set by the DHSS and state law. The DHSS completes an annual review to determine NME CDS participant’s continued eligibility.

NME CDS are not covered by Medicare or other third party insurance.

NOTE:  The amount the provider charges for the NME CDS are allowable incurred expenses to be used to meet the participant’s spend down.