0810.010.15.10 Authorizing Spend Down Coverage Based on Incurred Expenses – DSS Manuals

IM-08 January 24, 2012 ; IM-131 October 18, 2002 ; IM-126 October 3, 2002 ; IM-106 September 10, 2002

For participants meeting spend down with incurred medical expenses, the eligibility specialist will enter a comment on the Eligibility Unit Member Role (FM3Z or EUMEMROL) screen. The recording should include:

the date the participant provided the information,

the name and address of the provider,

date of service,

type of service,

the total amount the patient is responsible to pay,

the identity of any known or suspected liable third parties,

the documentation used to verify this information (such as a bill from the provider was viewed and a copy filed in the case record),

the date the MSPA screen entry is completed, and

the amount of liability on the date the spend down was met.

The MSPA screen requires the eligibility specialist to enter the date of service and the participant’s personal responsibility for that date of service rounded to the nearest whole dollar. Participant liability is the amount of the spend down that was met on that day, rounded down to the nearest whole dollar. The dates of service must be in a month for which spend down eligibility has been entered in FAMIS and cannot be a future month. The system will enter a coverage end date of the last day of the month for which coverage is being authorized.

EXAMPLE : Participant’s spend down for October is $100. They incur medical expenses for which they are personally responsible to pay of $75 on 10/1/12 and $50 on 10/2/12. The eligibility specialist enters the dates of service and participant’s responsibility on MSPA. The MSPA system will determine the participant’s liability of $25 on 10/02/12.

Upon receipt of verification that spend down has been met with incurred expenses for a month, the eligibility specialist will enter dates of service and participant’s liability on the MSPA screen.

Process new MHABD applications within normal application processing time frames. If the applicant has provided documentation of incurred medical expenses to meet spend down, the spend down liability cannot be entered on the MSPA screen on the same day the approval is entered in FAMIS. If bills to meet spend down are received prior to approval of the case, enter the MSPA screen the first working day after the approval is entered in FAMIS.

For active MHABD cases, enter the incurred medical expenses on the MSPA screen within 2 working days of receipt of documentation of medical expenses that meet spend down once the amount the third-party payment and personal responsibility has been determined.

The eligibility specialist must send the Spend Down Notification form IM-29(SPDN) to inform the participant that they met spend down with incurred expenses. The letter informs the participant of the MO HealthNet start date and the amount of spend down met on the start date. Send the IM-29(SPDN) on the date coverage is initially entered on the MSPA screen or corrected through the MSPU screen.