| TO: | ALL COUNTY OFFICES |
| FROM: | JANEL R. LUCK, DIRECTOR |
| SUBJECT: | OUT-OF-POCKET MEDICAL EXPENSES FOR SPENDDOWN CASES |
DISCUSSION:
Senate Bill 577 (2007) amended Section 208.153 RSMo to allow a reduction in spenddown for up to three months for a participant who paid a spenddown invoice and then paid an approved out-of-pocket medical expense in the same month. Effective immediately, if a MO HealthNet participant pays his or her invoiced spenddown amount for the month and also pays approved out-of-pocket medical expenses in the same month, the amount of the out-of-pocket medical expenses may be applied to the next three unpaid invoices.
First, apply the approved expenses to the next month's spenddown. If there is a remainder after applying the expenses to the next month, apply the remainder to the following month (the second month). Finally, if there is still a remainder, apply it to the third month's spenddown. Staff must have hard copy verification of paid out-of-pocket medical expenses.
County staff must complete an IM-29SPDN, Notification of Spenddown Coverage, notifying the participant of the remaining amount of spenddown expense to be met for any of the three months, if applicable. Counties must fax a copy of the completed IM-29SPDN to IM Program and Policy along with the hard copy verification of paid approved out-of-pocket medical expenses. The IM-29SPDN must be faxed to IM Program and Policy ATTN: Jessie Maupin, SOSA at (573) 751-3677. IM Program and Policy staff will apply the amount of expenses to the unpaid invoices. Invoices affected will display on the MSPI screen as met with bills under the Method field. IM Program and Policy will be working with MO HealthNet Division staff to ensure that the paid out-of-pocket medical expenses are applied.
Participants may continue to receive invoices for the months that expenses have been applied depending on when the information is received by IM Program and Policy. Because of the time factor involved with pulling an invoice, staff will need to fax the completed IM-29SPDN to IM Program and Policy the same day that it is completed. The information will then be given to Mo HealthNet Division to pull the invoices. If the participant later pays an invoice that the approved out-of-pocket medical expense was applied to, MO HealthNet Division will issue the participant a refund.
EXAMPLE: Mr. Avery pays his monthly spenddown invoice of $100 by check each month. He paid his September spenddown 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. Mr. Avery's out-of pocket medical expenses are applied to October for $100, November for $100 and December for $50 leaving a balance due for December of $50. The eligibility specialist completes an IM-29SPDN showing that Mr. Avery met his spenddown for the months of October and November. The eligibility specialist informs Mr. Avery on the IM-29SPDN that for the month of December his spenddown is $100 and that he provided $50 in medical expenses leaving $50 remaining spenddown for the month of December. The eligibility specialist faxes a copy of the IM-29SPDN to IM Program and Policy. IM Program and Policy contacts the MO HealthNet Division to apply the out-of-pocket expenses to the unpaid months. Mr. Avery may continue to receive invoices for the full amount; however, he will only owe $50.00 for December. Mr. Avery could either use bills to meet the reduced amount or could pay in the reduced amount to the MO HealthNet Division.
EXAMPLE: Ms. Ballard pays her monthly spenddown invoice of $150 by check each month. The MO HealthNet Division received her check for December spenddown on November 29, 2007. Ms. Ballard had dental expenses of $100 on December 18, 2007. She provided her bill showing that she paid for the services. The eligibility specialist applies the $100 to January 2008, and completes an IM-29SPDN showing that for the month of January her spenddown is $150 and that $100 is applied to the month of January leaving $50 remaining spenddown for the month of January. The eligibility specialist faxes a copy of the IM-29SPDN to IM Program and Policy. Ms. Ballard could either use bills to meet the reduced amount for January or she could pay in the reduced amount to the MO HealthNet Division.
EXAMPLE: Mr. Finestein pays his monthly spenddown of $30 by check each month. The MO HealthNet Division received his check for December spenddown 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 applies $30 to January, $30 to February, and $30 to March 2008, which is the maximum that can be applied (3 months of Mr. Finestein's spenddown). The eligibility specialist completes an IM-29SPDN showing that for the months of January, February, and March 2008 his spenddown is met. The eligibility specialist faxes a copy of the IM-29SPDN to IM Program and Policy.
AUTOMATIC WITHDRAWAL
Participants who have automatic withdrawal (Electronic Funds Transfer (EFT)) of their spenddown premium payment will continue to have the full invoiced amount deducted from their account. If the participant pays an approved medical expense in the same month that their spenddown payment was automatically withdrawn, a refund will be issued for the full or partial premium amount for the future unpaid month(s). The reason for this process is that EFT cannot begin and end without a new authorization being submitted, and the amount being withdrawn is based on the spenddown amount in the Legacy system.
NECESSARY ACTION:
- Review memorandum with appropriate staff.