MEMORANDUM

DISCUSSION:

Out-of-Pocket Expenses only apply to spend down cases where participants pay-in their spend down to the MO HealthNet Division (MHD). If a participant pays an eligible out-of-pocket medical expense in the same month that they have paid-in their spend down amount to the MHD, the out-of-pocket medical expense can be allowed as a reduction from their spend down amount for up to the next three month's from the date of the out-of-pocket expense. The reduction applies to unpaid invoices. Because the out-of-pocket expense can only be allowed for up to the next three months of unpaid invoices, participants should be encouraged to submit documentation of out-of-pocket expenses the same month that the service is received. Refer to Section 0810.010.15.05 for information regarding eligible medical expenses.

Policy manual revisions to clarify Out-of-Pocket Expenses for Spend Down have been added to 0810.010.20.20.

The Out of Pocket Expenses form (IM-29OPE) has been developed to provide an explanation of eligible and ineligible out-of-pocket expenses submitted by spend down participants who paid-in their spend down and then pay out-of-pocket for eligible medical expenses in the same month. The expenses entered on the form require supporting documentation such as a paid receipt. The form will also be used by regional policy liaison staff to enter eligible out-of-pocket expenses into MO HEALTHNET DIVISION ADD OUT OF POCKET EXPENSES (MSPO) screen.

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 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.

OR

Ineligible Out-of-Pocket Expense

When it is determined the participant 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. Make one copy of the form. (If expenses are from more than one month complete separate forms for each month.)
• 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.

The IM-29OPE form and instructions are available in the on-line forms and attached to this memo. It is not available in hard copy from the warehouse.

NECESSARY ACTION:

• Review this memorandum with all appropriate staff.
• Begin using the IM-29OPE form immediately.

ATTACHMENTS:

• IM-29OPE
• IM-29OPE Instructions

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