0810.010.20.20 Out-of-Pocket Expenses for Spend Down Cases – DSS Manuals

IM-15 February 22, 2012 ; IM-03 January 7, 2008

Senate Bill 577 (2007) amended RSMo 208.153 to allow a reduction in spend down for up to three months for a participant who paid a spend down invoice and then pays an eligible out-of-pocket medical expense in the same month. As of January 2008, if a MO HealthNet participant pays-in his or her invoiced spend down amount for the month and also pays eligible out-of-pocket medical expenses in the same month, the amount of the out-of-pocket medical expenses may be applied to reduce the amount owed on unpaid invoices for up to the next three months from the date of the expense. If the out-of-pocket expense exceeds the total of three month’s invoices, or if the documentation of the paid out-of-pocket expense is not received in time to apply it to the three month period following the date of the expense, the participant may not receive the benefit of the out-of-pocket expense reduction.

NOTE: When discussing PAID-IN spend down and out-of-pocket expenses with participants, explain that it is to the participant’s advantage to submit documentation of the paid expense in the same month the service is received and paid.

When a participant provides documentation that they have paid out-of-pocket medical expenses, within two (2) business days from receipt of documentation the eligibility specialist must view the MO HEALTHNET DIVISION PREMIUM INQUIRY SCREEN (MPNI) to verify the participant paid-in their spend down for the month for which bills for out-of-pocket medical expenses are submitted and determine if the payment was for an eligible medical expense.