0810.010.20.17 Combination of Incurred Medical Expenses and Pay-In – DSS Manuals

IM-56 July 2, 2012

Participants may combine incurred medical expenses and partial pay-in of a MHD invoice amount to meet spend down in one of the following ways:

submitting incurred medical expenses not subject to payment by a third party to the local Family Support Division (FSD) office and paying in the remainder of their spend down amount to the MO HealthNet Division (MHD) Premium Collections; or

submitting a partial payment of their spend down amount to the MHD Premium Collections and submitting incurred medical expenses not subject to payment by a third party to the local Family Support Division (FSD) office. NOTE: Incurred medical expenses can be carryover and/or current expenses. See Section 0810.010.15 Meeting Spend Down With Incurred Expenses .

Participant Submits Bills Prior to Submitting Payment

When a participant sends incurred expenses to the local FSD office that do not meet their spend down liability, the eligibility specialist (ES) determines the remaining spend down liability and sends the participant the Spend Down Notification (IM-29(SPDN)) form to inform the participant that they need to provide additional bills or partial pay-in to meet spend down. If they choose to mail a partial payment to the MHD Premium Collections, the participant should include the IM-29 (SPDN) Spend Down Payment Option page and their invoice, if available.

If a participant makes a partial payment for the same month that the medical expenses are incurred, spend down coverage starts from the last date of service when total expenses plus partial payment meets the spend down amount.

If there are carryover incurred expenses from the prior three months combined with partial payment, spend down coverage starts on the first date of the month coverage is selected by the participant.

Participant Submits Payment Prior to Submitting Bills

If the participant sends partial payment to the MHD Premium Collections, the partial payment is held for 60 days from the last day of the month the payment is received. MHD will notify the MO HealthNet (MHN) Program and Policy to determine if incurred medical expenses have been submitted.

Processing Partial Payments

MHD will send a notice to MO HealthNet (MHN) Program and Policy that a partial payment has been received including:

participant’s name and DCN,

date received,

amount of the payment, and

month payment should be applied if different than the month received (if known).

MHN Program and Policy corresponds with the local FSD office to determine if incurred expenses have been received and the start date of coverage.

MHN Program and Policy enters spend down liability and date in MO HEALTHNET DIVISION ADD spend down COVERAGE (MSPA) screen and updates the Method field code in MO HEALTHNET DIVISION spend down UPDATE (MSSU) screen to “O” for other, and notifies MHD to process the payment.

MHN Program and Policy notifies the local FSD office to send an IM-29(SPND) form to the participant notifying them of the date spend down was met.

EXAMPLE: Mr. Brown has a spend down liability of $300. He incurs a $200 dentist bill on August 7th and knows that he has a future surgery in the same month. Mr. Brown does not want to wait for the bills from his surgery in order to activate his spend down. Mr. Brown provides his $200 dentist bill to the ES and then sends the remaining $100 he owes with the IM-29 (SPND) Spend Down Payment Option page to MHD. After MHD receives the payment, Mr. Brown’s coverage begins on August 7th.

MONTH SPEND DOWN LIABILITY COUNTABLE MEDICAL EXPENSES PAYMENTS TO MHD PREMIUM COLLECTIONS 08/2012 $300 $300-$200 Incurred Expenses = $100 N/A 08/2012 $300 N/A $100 – $100 Payment (Applied to August)

EXAMPLE : Mrs. Collins has a spend down of $1200. She incurred expenses of $500 in July, $200 in August, and provides these bills to the local FSD office on September 3rd. On September 8th, MHD receives a partial payment of $500 from Mrs. Collins with her September invoice. The ES will receive notification from MHN Program and Policy indicating a partial payment has been received by MHD. The ES contacts MHN Program and Policy to enter the bills for her September spend down. MHN Program and Policy will then notify MHD to apply the partial payment to September. Her spend down for September is met on September 1.

MONTH SPEND DOWN LIABILITY COUNTABLE MEDICAL EXPENSES PAYMENTS TO MHD PREMIUM COLLECTIONS 07/2012 $1200 $1200-$500 = $700 (spend down not met) None 08/2012 $1200 $700-$200 Incurred Expenses = $500 (spend down not met) None 09/2012 $1200 N/A $500 Payment (Applied to September combined with July and August carry over expenses meets spend down)