MEMORANDUM

DISCUSSION:

The purpose of this memo is to clarify the Department of Mental Health (DMH) services that are allowable incurred expenses to meet spend down, even when the expenses are billed to and eligible for payment by the DMH.

According to 42 CFR 435.121(f)(1)(iii):  Allowable expenses for use toward an individual's spend down are expenses incurred by the individual or spouse, whose income is used in determining eligibility, for necessary medical services that are recognized under State law and are not subject to payment by a third party, unless the third party is a public program of a State or political subdivision of a State such as Department of Mental Health or Department of Health and Senior Services. To incur an expense means to be personally responsible for the expense.

The DMH has three Divisions, the:

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

Each Division has its own services and providers, along with rules on when the providers are to bill the participant or the DMH for the services provided. 

DIVISION OF DD SERVICES
DIVISION OF CPS AND ADA SERVICES
IDENTIFYING DMH MEDICAL SERVICES ALLOWABLE FOR SPEND DOWN
VERIFICATION OF DMH MEDICAL EXPENSES
MANUAL SECTIONS ADDED

DIVISION OF DD SERVICES

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

• Comprehensive Waiver;
• Missouri Children with Developmental Disabilities Waiver (MOCDD) or Sarah Lopez Waiver;
• Community Support Waiver;
• Partnership for Hope; and
• Autism Waiver.

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

NOTE:  If the recipient of these services is a spend down participant, the amount the provider charges for the services are allowable incurred expenses to be used to meet the participant's spend down. 

DIVISION OF CPS AND ADA SERVICES

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. The Division of CPS also provides Targeted Case Management (TCM) for adults with serious mental illness (SMI) and children with a severe emotional disturbance (SED). Community Mental Health Centers (CMHC) are the providers for CPR and TCM. A listing of the current Community Mental Health Centers (CMHC) is located at http://dmh.mo.gov/mentalillness/org/adminagents.htm.

The Division of ADA administers Comprehensive Substance Treatment and Rehabilitation (CSTAR), which provides substance abuse treatment including a combination of clinical and supportive services and temporary living arrangements when appropriate. CSTAR services are provided by organizations that have a contract with and are certified by ADA. A listing of CSTAR providers is located at http://dmh.mo.gov/ada/resourcemapsinfo.htm.

CPR, CSTAR, and TCM are medical services covered in the Missouri Medicaid State Plan.  The CPS and ADA Divisions provide these services through contracted providers. The providers bill the DMH for the services administered. Then, the providers are paid from funds appropriated to the DMH in the state budget. If the consumer is not on MO HealthNet or has not met spend down, the DMH uses all state funds to pay the provider.

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

NOTE:  If the recipient of these services is a spend down participant, the amount the provider charges for the services are allowable incurred expenses to be used to meet the participant's spend down. 

IDENTIFYING DMH MEDICAL SERVICES ALLOWABLE FOR SPEND DOWN

The four types of DMH medical services that are not covered by Medicare or other third party insurance and are allowable towards a participant's spend down can be identified through the provider type, designated by the first two digits of the Medicaid provider number.  

Each is billed using a provider type that is specific to the services:

• 87 - Community Psychiatric Rehabilitation (CPR)
• 86 – Comprehensive Substance Abuse Treatment and Rehabilitation (CSTAR)
• 85 – Developmentally Disabled 1915(c) waiver services
• 15 – Targeted Case Management (TCM) for Individuals with Developmental Disabilities (DD), for adults with Serious Mental Illness (SMI), and for children with a Severe Emotional Disturbance (SED)

VERIFICATION OF DMH MEDICAL EXPENSES

Obtain the following documentation for the DMH services, not covered by Medicare or other third party insurance, that are allowed as incurred expenses for spend down:

• Name and DCN of the MO HealthNet participant
• Name of service provider
• Provider type (First two digits of the provider number)
• Date the service was provided
• Service provided, identified in one of the four categories – CPR, CSTAR, Targeted Case Management, or DD waiver.  It does not have to include the specific service name or procedure code.
• Charge for service on the date it was provided

There is not a required format, but it needs to include all of the above information.    

MANUAL SECTIONS ADDED

The Income Maintenance policy manual sections 0810.010.15.15.05, 0810.010.15.15.10, and 0810.010.15.15.20 have been added to identify:

• The DMH medical services not covered by Medicare or other third party insurance that may be paid for by the DMH with state funds;
• Provider Types that provide these services;
• Verification to be used to verify allowable incurred expenses to meet spend down;
• Link to the DMH website listing of Community Mental Health Centers (CMHC) and CSTAR providers.

NECESSARY ACTION:

• Review this memorandum with appropriate staff.

HA