MEMORANDUM

DISCUSSION:

Effective September 18, 2012, a new version of the MO HealthNet Spend Down Provider Form is available. Revisions to the form have been made based on recommendations from providers and staff.  Changes include:

• Addition of check boxes to denote the type of provider;
• Addition of check boxes to denote out-patient and in-patient hospital charges;
• Update to terminology in required fields;
• Formatting;
• Addition of a line for provider to initial when the required fields are completed based on  a good faith estimate of expenses billable to the patient; and
• Addition of instructions for completion of the form.

Upon receipt of a request for coverage of medical services received by a MO HealthNet spend down participant, the eligibility specialist should request a copy of a receipt or bill to the customer to verify countable medical expenses and amount of participant's responsibility to pay, and the date spend down is met.  The receipt or bill must include:

• date of service(s),
• type of service(s) provided,
• charge for service(s) provided,
• amount of third party liability, and
• amount that the participant or spouse is responsible to pay.

A bill is a statement of a liability by one party to another party following a transaction.  For the purposes of determining eligibility for MO HealthNet spend down coverage, the transaction is the medical services provided and received.

A receipt is a printed acknowledgment from the provider that payment has been received from the participant for medical services provided.  An incurred medical expense does not have to have been paid to be allowed to meet spend down.  However, the expense must be the responsibility of the participant to pay.  See Manual Section 0810.010.15.05 Countable Medical Expenses for Spend down.

The MO HealthNet (MHN) Spend Down Provider Form must be completed when a receipt or a bill to the patient is not available.  The MHN Spend Down Provider form must be completed by the provider of the services, an authorized employee of the provider, or an authorized employee of an agency contracted to provide billing services for the provider. The individual completing the form is attesting to the accuracy of the information and must be able to verify the amount billed to the patient.  The MO HealthNet Spend Down Provider form is available on the internet at https://dss.mo.gov/fsd/massist.htm.

NOTE:  Attachments providing the information requested on the form may be submitted in place of completing each column.  (See MO HealthNet Spend Down Provider Form Instructions)

A receipt, bill, or a completed MHN Spend Down Provider Form is acceptable documentation of the amount of the participant's responsibility for incurred medical expenses.  Within 2 days of receiving documentation of medical expenses, the eligibility specialist must send an IM-29(SPDN) to notify participants:

• when their spend down liability is met;
• when documentation of incurred medical expenses does not meet their spend down liability; and
• when incurred medical expenses were not allowed to meet their spend down and why.

The MO HealthNet for Aged Blind and Disabled Manual section 0810.010.15.01  is revised to include the requirement of a completed MO HealthNet Spend Down Provider Form or a bill to the customer or a receipt for payment of medically necessary services provided to the customer as acceptable documentation of allowable expenses to meet spend down.

The MO HealthNet for Aged Blind and Disabled Manual section 0810.010.15.15.20 is revised to include the exception of the requirement of a bill for MO HealthNet participants who incur expenses paid by Department of Mental Health (DMH).  These expenses can be verified by an invoice to DMH or a completed MO HealthNet Spend Down Provider Form.

NECESSARY ACTION:

• Review this memorandum with appropriate staff.
• Request a copy of a receipt or bill to the customer when MO HealthNet coverage is requested by a spend down participant.
• Use a completed MO HealthNet Spend Down Provider Form with a revision date of 09/12 as acceptable documentation of incurred medical expenses to meet spend down liability when a receipt or bill is not available.
• Accept prior version of the MO HealthNet Spend Down Provider Form through October 31, 2012.

AC/kso