Federal Medicaid regulation 42 CFR 435.121 sets forth the requirements for “Individuals in States using more restrictive requirements for Medicaid than the SSI requirements.” Missouri Revised Statutes Chapter 208, Section 208.151 sets forth the legal basis for MO HealthNet coverage.
The beginning date of the claimant's MO HealthNet coverage depends on whether they are eligible on a non-spend down or spend down basis.
For non-spend down cases the participant's eligibility for MO HealthNet coverage begins with the first day of the month of application, provided the participant is subsequently found eligible, and was not obviously ineligible for the entire month of application and any subsequent month prior to approval. If the participant was obviously ineligible for the entire month of application and any subsequent months prior to approval, the MO HealthNet eligibility date begins with the first day of the month in which eligibility was met.
EXAMPLE: The participant submits the application on June 18. The participant is ineligible because of excess resources until the resources have been reduced on July 3. MO HealthNet eligibility begins July 1.
Effective October 1, 2002 eligibility for MHABD spend down is computed on a monthly basis. If the participant is eligible for MHABD on a spend down basis, MO HealthNet coverage for the month begins with the date on which the spend down is met and ends on the last day of that month. The MO HealthNet Division's (MHD) system prevents payment of medical services equal to the participants spend down liability on the date that MO HealthNet coverage is started.
MO HealthNet coverage will begin and end without the case closing at the end of the monthly spend down period. As long as the participant remains eligible on all factors, except having met spend down, the case will remain active.
The participant may choose to meet their spend down by either of the following options:
Prior Quarter MO Health Net Spend Down Coverage
To meet spend down in the three months prior to the month of application (prior quarter,) the participant must submit verification of allowable incurred medical expenses that are not subject to payment by a third party. The participant is not allowed to pay-in their spend down for the three months prior to the month of application. Refer to manual sections 0810.010.15 Meeting Spend Down with Incurred Expenses and 0810.010.15.01 Documentation of Incurred Medical Expenses.
Approval Month and Future Months Coverage:
In the month of approval and future months participants have the option of changing the method in which they meet their spend down each month. Participants make the choice by sending the payment to MHD Premium Collections or submitting bills for medical expenses not payable by a third party (that the participant is personally responsible to pay) to the FSD. The participant may combine incurred expenses with partial payment to MHD Premium Collections. Refer to Manual Sections 0810.010.15 Meeting Spend Down with Incurred Expenses; 0810.010.20 Spend Down Pay-In Option; and 0810.010.20.17 Combination Of Incurred Expenses and Pay-In.
NOTE: For those months that participants do not pay-in, submit incurred medical expense or combine incurred medical expenses and partial payment to meet spend down liability, they do not have MO HealthNet coverage. Refer to Manual Section 0810.010.15 Meeting Spend Down with Incurred Expenses.