IM-08 January 24, 2012; IM-138 October 24, 2003; IM-106 September 10, 2002
On spend down cases MO HealthNet is only to reimburse providers for covered medical expenses that exceed a participant’s spend down amount. MO HealthNet will not pay the portion of a bill used to meet the spend down. To prevent MO HealthNet from paying for an expense used to meet spend down, MHD withholds the participant liability entered on MSPA from claims submitted for the first day of coverage for a month.
The MHD system tracks the bills they receive for the first day of coverage, until the bills equal the participant’s remaining spend down liability. For the first day of coverage, MHD will deny or split (partially pay) the claims until the participant’s liability for that first day is reduced to zero. After MHD has reduced the liability to zero for the first day of coverage, other claims submitted for that day will be paid up to the MO HealthNet rate. Claims for all other days of spend down coverage will process in the same manner as those of non-spend down participants. MHD will notify both the provider and the participant of any claim amount not paid due to the bill having been used to meet spend down.
EXAMPLE: Participant’s spend down amount for October is $150.00. On October 4th, the participant goes to the doctor and is billed for $50.00; they also charge prescriptions of $150.00 on October 4th. The participant does not have health insurance or Medicare. On October 5th the bills are provided to the eligibility specialist, who enters the date of service and participant’s responsibility into the MSPA screen. The next day the MO HealthNet Division system will show a coverage period of 10/04 to 10/31 with participant liability of $150.00.
Claims for 10/04 will be compared to the participant liability amount when they are received. If the doctor’s bill is submitted to MO HealthNet first, it will not be paid. The MO HealthNet system will subtract the doctor bill from the total participant liability ($150.00 – $50.00) and reduce the participant liability for 10/04 to $100.00. When the $150.00 pharmacy bills are received, they will be compared to the remaining participant liability of $100.00. The MO HealthNet system will calculate the remaining participant liability of $100.00 was met with the pharmacy bill, and will pay the pharmacy the MO HealthNet rate for that prescription, minus $100.00.
When a participant has multiple expenses on the day spend down is met and the total expenses exceed the remaining spend down, the liability amount may be withheld from the wrong claim. This could occur if provider A submits a claim to MHD and provider B does not (either because the bill was paid or it was a non-MO HealthNet covered service). Since the MHD system can only withhold the participant liability from claims submitted, the liability amount would be deducted from the bill of the provider A. Provider B’s bill may have been enough to reduce the liability to zero, which would have allowed MO HealthNet to pay the provider A’s claim. MHD Participant Services unit will authorize payment of the submitted claim upon their receiving verification of other expenses for that day which would reduce the liability to zero. Participant Services may request documentation from the case record of bills the county used to meet spend down on the day it was met. The documentation for that day should be sent to Participant Services.
EXAMPLE: Participant’s spend down amount for November is $50.00. On November 5th, participant goes to a MO HealthNet doctor and is billed for $50.00. They also incur a $50 expense for a chiropractor visit on November 5th. Since chiropractor services are not covered by MO HealthNet, this bill will not be submitted to MO HealthNet. When the doctor bill is submitted to MO HealthNet, nothing will be paid on it as it does not exceed the participant liability for the 5th. If Participant Services receives verification of the chiropractor expense, MO HealthNet will pay the doctor’s bill.