MEMORANDUM

DISCUSSION:

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

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 DHSS Division of Senior and Disability Services (DSDS) administers the Non-Medicaid Eligible (NME) Personal Care Assistance (Consumer-Directed Services Model) (CDS) program. 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.  The DHSS approves the participant for NME CDS units of care. The approved units of care are included in the care plan established through the DHSS.  

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

NME CDS are provided through the Medicaid State Plan (MSP). NME CDS are not covered by Medicare or other third party insurance. 

NOTE:  If the recipient of the NME CDS is a spend down participant, the amount the provider charges for the DHSS approved units of CDS are allowable incurred expenses to be used to meet the participant's spend down. 

NOTE: There are many other spend down participants that use Consumer Directed Services that are not funded by the DHSS. The CDS that are not NME CDS, and are not subject to payment by a third party, are also allowable expenses towards spend down.

IDENTIFYING DHSS NME PARTICIPANTS
VERIFICATION OF DHSS MEDICAL EXPENSES
MANUAL SECTIONS ADDED

IDENTIFYING DHSS NME PARTICIPANTS

There are currently forty-nine NME CDS participants statewide. Of these, eighteen are spend down participants. MO HealthNet (MHN) Program and Policy will provide a listing to the local offices of active NME CDS participants and a copy of their care plan. The listing will include the name of the participant, the provider's name, the participant's DCN, and the CDS units that the DHSS has authorized.

The DHSS will notify MHN Program and Policy of any changes in participants, including the addition of new participants or the termination of a participant's eligibility. MHN Program and Policy will then notify the local office of the change in eligibility for the program. 

Each year when the DHSS completes the annual review of their eligibility, the DHSS will send a current copy of their care plan, including any change in their authorized units of CDS. If the DHSS determines the participant is eligible for a change in units, the DHSS will notify MHN Program and Policy. MHN Program and Policy will then notify the eligibility specialist and supervisor. 

VERIFICATION OF DHSS MEDICAL EXPENSES

The appropriate documentation  to obtain as verification of the DHSS NME CDS, not covered by Medicare or other third party insurance, that are allowable as incurred expenses for spend down must include:

• Name and DCN of the MO HealthNet participant
• Name of service provider
• Date the service was provided
• Service provided
• Charge for service on the date it was provided
• Copy of care plan

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

The date a medical expense is incurred is the date the individual receives the service, not the date of the bill or the date a bill is paid. The service provided should show CDS.  A copy of the care plan is needed to verify the units of care the DHSS has authorized for NME CDS.

MANUAL SECTIONS ADDED

The Income Maintenance policy manual sections 0810.010.15.15.05, 0810.010.15.15.15, and 0810.010.15.15.25 have been added to identify:

• Definition and description of the DHSS NME CDS program;
• How FSD offices will be notified of the DHSS NME CDS participants; and
• Verification to be used to verify allowable incurred expenses to meet spend down.

NECESSARY ACTION:

• Review this memorandum with appropriate staff.

HA