13 CSR 40-2.395 - Spend Down Program
(1) Spend down is a program created for
persons with disabilities and persons aged sixty-five (65) and older who have
income that exceeds the Medicaid qualification limits. Such individuals may
qualify for Medicaid benefits when they spend down their income that exceeds
the Medicaid eligibility limit. Medicaid coverage begins when the individual's
incurred medical expenses equal the monthly spend down requirement.
(2) Definitions.
(A) "Incurred medical expenses" means
expenses incurred by the individual or financially responsible relatives for
necessary medical and remedial services that are recognized under state law and
are not subject to payment by a third party, unless the third party is a public
program of a state or political subdivision of a state. Incurred medical
expenses include Medicare and other health insurance deductibles and
co-insurance charges, and co-payments or deductibles imposed under
42 C.F.R. Section
447.51 or Section
447.53. The term incurred medical
expenses includes expenses incurred by an individual's spouse whose income is
included in the Medicaid eligibility determination.
(B) "Individual" means aged persons (over
sixty-five (65) years), blind persons, or people with disabilities with income
above limits established under section
208.151, RSMo, for MO HealthNet
for the Aged, Blind, and Disabled, permanent and total disability benefits, or
aid to the blind benefits.
(C)
"Third party" means a Medicare, private health insurance, or other health care
payer.
(3) How spend down
amount is calculated. The monthly spend down amount is calculated as the
difference between the individual's monthly net income and the Medicaid
eligibility limits. The net income is calculated according to the provisions of
13 CSR
40-2.200.
(4) Spend down may be met in one (1) of the
following ways:
(A) Incurred Costs Method.
Spend down participants using this method must provide documentation of medical
expenses they have incurred.
1. Incurred
medical expenses that can be applied to spend down must be either-
A. Incurred within the month MO HealthNet
coverage is requested and bills are submitted to the Family Support Division;
or
B. Incurred within the three (3)
months prior to the month for which MO HealthNet coverage is requested and
bills are submitted to the Family Support Division for those eligible for MO
HealthNet Aged, Blind, and Disabled spend down program;
C. Incurred medical expenses can be applied
to future months limited to a maximum of three (3) months from the current
month in which MO HealthNet coverage is requested when-
(I) The bills were incurred while the
participant was eligible for MO Health-Net spend down;
(II) The bills were not paid and will not be
paid by MO HealthNet;
(III) The
bills are currently owed or paid by the participant;
(IV) The bills were not previously applied in
any month to meet spend down, including use of out-of-pocket expenses;
and
(V) The bills were incurred no
earlier than three (3) months prior to the current month;
D. Allowable medical expenses include those
specified in section 208.152, RSMo; and
E. Proof of incurred costs does not require
proof of payment of the incurred costs.
2. In order for an individual to claim that
an incurred medical expense should be credited to the individual's spend down
obligation, the individual shall provide documentation of the incurred medical
expense within one (1) year of the date of the medical service.
3. No credit for incurred medical expenses
shall be given without documentation that the individual has incurred, and is
legally obligated to pay the expense, and has not previously used the expense
for spend down. Documentation of an incurred medical expense shall be submitted
in either one (1) of the following methods:
A.
An invoice, billing statement, or receipt from the provider that contains the
following information:
(I) Name of
patient;
(II) Date of
service;
(III) Type of service
provided and/or description of the service;
(IV) Identification of the portion of the
total charges that are billed to a third party and the portion of the total
charges that are the patient's responsibility to pay; and
(V) To document incurred costs of mileage of
medically necessary, nonemergency transportation, the individual shall certify
the miles traveled and the purpose. Travel expenses required to obtain a
medical item or service shall be determined at the State Employee Reimbursement
rates established by the state of Missouri Office of Administration pursuant to
1 CSR
10-11.010 and
1 CSR
10-11.030 as of the date of travel; or
B. A Family Support Division
Provider form signed and completed by the provider containing the information
set out in subparagraph (4)(A)3.A. of this regulation.
4. The provider shall, upon request, provide
any additional information required by the Family Support Division to establish
that the individual has incurred the medical expense.
5. When it is known that the individual has
coverage by a third party and the portion subject to payment by the third party
cannot be identified, the Family Support Division shall-
A. For individuals with private health
insurance or coverage by another healthcare payer, estimate the amount of the
individual's incurred cost based upon the provisions of coverage; and
B. For individuals with Medicare Part A
and/or B coverage and who do not have Qualified Medicare Beneficiary coverage,
estimate the amount of the individual's incurred medical cost to be-
(I) One hundred percent (100%) of the
Medicare reimbursement rate up to the individual's Medicare deductible, if the
deductible has not been met; and thereafter
(II) Twenty percent (20%) of the Medicare
allowable reimbursement once the deductible has been met.
6. Individuals receiving Qualified
Medicare Beneficiary coverage cannot use incurred medical expenses covered by
Medicare towards meeting spend down.
7. If a provider provides a direct medical
service based on an "ability-to-pay" or "sliding" fee scale, only the amount
the individual is legally obligated to pay the provider is an incurred medical
expense;
(B) Pay-in
Method. An individual may pay their spend down amount to the state. The monthly
spend down requirement may be paid by the individual, their spouse, a
financially responsible relative, or a public program of a state or political
subdivision of a state; and
(C)
Combination Method. An individual may use a combination of the incurred costs
method and the pay-in methods to satisfy the monthly spend down amount to the
state.
(5) Any individual
who disagrees with the FSD's decision shall have the right to request
administrative review pursuant to 208.080, RSMo, and
13 CSR
40-2.160.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.