ELIGIBLE OUT-OF-POCKET EXPENSE

When it is verified that the spend down was paid-in and there was an eligible paid medical expense:

The eligibility specialist must: Complete the Out of pocket Expenses form (IM-29OPE) noting Yes for eligible expense, and make one copy (If expenses are documented for more than one month, complete separate forms for each month.) Scan the completed IM-29OPE and supporting documentation, and send to the eligibility specialist (ES) supervisor

The ES supervisor will: Review the IM-29OPE and supporting documentation Upon approval forward it to the regional policy liaison

The regional policy liaison will: Enter the information on the MSPO screen, Notify the eligibility specialist and ES supervisor that the entries have been made Email MHD contacts to ensure that the paid out-of-pocket expenses are applied timely and correctly to the MHD invoicing system

When notification is received from the regional policy liaison, the eligibility specialist will mail the IM-29OPE to the participant and file one copy in the IM case record.

The day following the entry on the MSPO screen, invoices affected will display as spend down met with “bills” in the “method” field on the MO HEALTHNET DIVISION spend down COVERAGE INQUIRY (MSPI) screen. In addition, the DIVISION OF MEDICAL SERVICES OUT-OF-POCKET EXPENSE HISTORY (MSPH) screen will show the invoices that the eligible charges entered were applied to and the amounts applied to the invoice.

NOTE: Out-of-pocket expenses can only be applied when a participant has PAID I N their spend down invoice, then pays for a medical service out-of-pocket in the same month. They cannot be applied after a participant has met their spend down with incurred or paid bills.

Participants may continue to receive invoices for the months that expenses have been applied, depending on the when the information is received by the eligibility specialist and the regional policy liaison enters it into MSPO, and when the MHD invoicing system applies the out-of-pocket expense. Due to the process to adjust an invoice, staff must scan and send the documentation along with the IM-29OPE to the supervisor and the supervisor must forward the completed forms and documentation to the regional policy liaison the same day the IM-29OPE is completed.

Participants who submit out-of-pocket expenses and have questions regarding their invoices and necessary payments should be directed to call MHD Premium Collections at 877-888-2811.

NOTE: If a participant pays the full invoice amount after an eligible out-of-pocket expense was applied, the out-of-pocket expense will be manually moved by MHD to the invoiced amount for the next month. MHD will not issue a refund to the participant. If a participant continues to pay full invoice amounts, MHD will only manually move out-of-pocket expenses for a maximum of 6 months.

EXAMPLE: Mr. Avery pays his monthly spend down invoice of $100 by check each month. He paid his September spend down on August 28, 2007. Mr. Avery had dental expenses of $250 on September 2, 2007. Mr. Avery reported that he paid out-of pocket dental expenses for September to his eligibility specialist on September 5, 2007, and provided his bill from the dentist office showing that he paid for his services. Mr. Avery has not sent in his payment for the invoice for the month of October. The eligibility specialist completes the Out-of Pocket Expense Form (IM-29OPE) to show the expense applied for the following 3 months, October, November, and December.

Depending on the date the expense documentation is received and entered, it may be applied $100 for October, $100 for November and $50 for December, leaving $50 of the $100 spend down to be invoiced for December. Unless additional out-of-pocket expenses are entered in November and December, or a budget adjustment is entered or MHD manually moves out-of-pocket expenses, the January invoice will return to the full $100 spend down amount.

EXAMPLE: Mr. Finestein pays his monthly spend down invoice of $30 by check each month. The MO HealthNet Division received his check for December spend down on November 28, 2007. Mr. Finestein had dental expenses of $100 on December 14, 2007, and provided his eligibility specialist a copy of the bill showing that he paid for the services. The eligibility specialist completes the Out-of Pocket Expense Form (IM-29OPE) reflecting December PAID expenses applied for the following 3 months, January, February, and March.

As three months is the maximum number of months the paid expense can be applied and his spend down amount is $30 per month, depending on the date the expense documentation is received and entered, the out-of-pocket expense may be applied as follows: $30 to January, $30 to February and $30 to March. The $10 remaining from the $100 paid on December 14, 2011 cannot be applied to an invoice as in doing so it would exceed the three month period following the month of paid out-of-pocket expenses.