0840.010.35 Change in Coverage – Spend Down and Ticket to Work – DSS Manuals

IM-113 July 17, 2020

When eligibility for more than one MHABD coverage type exists, participants may request to change their level of coverage. This commonly occurs between the Spend Down and Ticket to Work programs.

Decisions regarding coverage options must be made by the participant or their Authorized Representative. Some of these changes can cause a significant cost difference for the participant. It is the responsibility of FSD staff to contact the participant to discuss their coverage options, and record the participant’s coverage choice in the eligibility system. If the participant does not respond to a Request for Contact letter within 10 days, FSD staff shall enter a decision reflective of past coverage history or the lowest cost option.

It is the responsibility of FSD staff members to contact the participant when they question that the participant fully understands the coverage that they and/or their Authorized Representative have requested.

EXAMPLE: Ms. Scott’s income allows her two MHABD coverage options: Spend Down of $832 or Ticket to Work with a premium of $156 per month. At the time of approval Ms. Scott chose the Ticket to Work program as the premium amount was lower. Six months later Ms. Scott is admitted to the hospital and has not paid in her monthly premium. She requested to change to Spend Down coverage as she can utilize that coverage like a deductible. Ms. Scott submits her request in writing via a fax that hospital staff assisted her in sending. The FSD staff member calls Ms. Scott and discusses the coverage options and ensures that Ms. Scott understands the coverage that she has requested and that she will owe the Spend Down amount to the provider.

Changes in coverage are treated as a “change in circumstance” and can be made effective the month of the request, unless an adverse action notice is legally required. An adverse action notice is legally required when there is a decrease in coverage or increase in Spend Down or TWHA premium. An adverse action period can be waived when the participant has signed a written statement voluntarily requesting the change in coverage, or has signed the Waiver of 10-day Advance Notice (IM-80A) form.

Refer to the Hearings Manual 0130.015.20 Exceptions to Advance Notice of Adverse Action for additional information.

NOTE : The eligibility system will send an Adverse Action Notice even if the participant has waived the adverse action time period. The signed waiver allows staff to enter worker-initiated budget calculation entries for this time period.

If the eligibility system does not adjust the appropriate months, staff should complete necessary actions, such as worker-initiated budget calculation entries, to ensure that correct coverage is issued.

The first business day after worker-initiated budget calculations are entered, confirm the coverage in the eligibility system and notify the MO HealthNet Division of the change in premium or spend down amount by sending an email to MHD.PremiumPayments@dss.mo.gov .

EXAMPLE : Mr. Andrews submits a request in writing on 10/07/2019 that his coverage be changed from Ticket to Work with a $42 premium to MO HealthNet with a Spend Down of $402 per month. He would like for this change to be effective immediately. Because the request is made in writing an Adverse Action is not required. The staff member enters the coverage change and the authorization allows for the Spend Down coverage to begin in January 2020. Worker Initiated Budget Calculations must be entered for the months of October, November, and December 2019.

Due to a hospitalization, or similar medical hardship, that occurs at the end of a month, if the participant was unable to request a change in level of coverage in the month of their admittance to the hospital they can request the change of coverage up to the 10 th calendar day following the medical event and have the request be applied retroactively to the prior month if the event occurred in the prior month. For hospitalizations, the date of the event is the date of admittance to the hospital.

EXAMPLE: Ms. Willis, a TWHA participant is admitted to the hospital on January 28, 2020, and reports this on February 3, 2020, when she requests Spend Down coverage for January ongoing. The request was made within 10 days of the event, therefore coverage may be changed for January ongoing. In the same situation, if the change was requested more than 10 calendar days after admittance to the hospital the coverage could be updated only for the month in which the request was made.

Re-application:

When an individual with a case that has recently closed, reapplies for coverage, another coverage type may be authorized for the prior quarter months IF the spend down has not been met, or the Ticket to Work premium has not been paid, for the months being requested. Spend Down/Ticket to Work coverage must not be changed for any month the individual met his/her spend down or paid in his/her Ticket to Work premium.

EXAMPLE: Mr. Webster failed to complete a reinvestigation for his MO HealthNet Spend Down case. His case closed effective January 30, 2020. He had not met his spend down since he was approved a year earlier. On February 25, 2020, he reapplied, and requested Ticket to Work coverage instead of Spend Down coverage. Mr. Webster is eligible for Ticket to Work coverage in the prior quarter and ongoing, IF he had not met his spend down in those months.

Cases requiring a Medical Review Team (MRT) decision :

When a participant is eligible for Ticket to Work coverage based on an MRT decision, they are not automatically eligible for other MHABD coverage. If an individual’s earnings are over the Substantial and Gainful Activity (SGA) threshold, they are not eligible for Spend Down or Non-Spend Down coverage. Decisions regarding SGA must still be entered by MRT, even if the participant’s earnings appear to exceed the SGA. Refer to MHABD Manual section 1060.005.12 Submitting Information to MRT for Individuals Engaged in Substantial Gainful Activity for additional information.

When an MRT decision is needed for the request for change in coverage, the income and tax withholding status must be verified. If the current system entries reflect the participant’s current income and tax withholding status, this information is considered verified for this purpose. If there is a change in income, verification must be requested and entered into the eligibility system prior to requesting that MRT review the case. Requests to have the MRT decision reviewed must be emailed to MRT.ProcessingCenter@dss.mo.gov .