0810.010.15.15  Preventing MO HealthNet Payment of Expenses Used to Meet Spend Down

IM-#8, January 24, 2012, IM-138,  October 24, 2003IM-106,  September 10, 2002

On spend down cases MO HealthNet is only to reimburse providers for covered medical expenses that exceed a participant's spend down amount.  MO HealthNet will not pay the portion of a bill used to meet the spend down.  To prevent MO HealthNet from paying for an expense used to meet spend down, MHD withholds the participant liability entered on MSPA from claims submitted for the first day of coverage for a month.

The MHD system tracks the bills they receive for the first day of coverage, until the bills equal the participant's remaining spend down liability.  For the first day of coverage, MHD will deny or split (partially pay) the claims until the participant's liability for that first day is reduced to zero.  After MHD has reduced the liability to zero for the first day of coverage, other claims submitted for that day will be paid up to the MO HealthNet rate.  Claims for all other days of spend down coverage will process in the same manner as those of non-spend down participants.  MHD will notify both the provider and the participant of any claim amount not paid due to the bill having been used to meet spend down.

EXAMPLE: Participant's spend down amount for October is $150.00. On October 4th, the participant goes to the doctor and is billed for $50.00; they also charge prescriptions of $150.00 on October 4th. The participant does not have health insurance or Medicare. On October 5th the bills are provided to the eligibility specialist, who enters the date of service and participant’s responsibility into the MSPA screen. The next day the MO HealthNet Division system will show a coverage period of 10/04 to 10/31 with participant liability of $150.00.

Claims for 10/04 will be compared to the participant liability amount when they are received. If the doctor's bill is submitted to MO HealthNet first, it will not be paid.  The MO HealthNet system will subtract the doctor bill from the total participant liability ($150.00 - $50.00) and reduce the participant liability for 10/04 to $100.00.  When the $150.00 pharmacy bills are received, they will be compared to the remaining participant liability of $100.00.  The MO HealthNet system will calculate the remaining participant liability of $100.00 was met with the pharmacy bill, and will pay the pharmacy the MO HealthNet rate for that prescription, minus $100.00.

When a participant has multiple expenses on the day spend down is met and the total expenses exceed the remaining spend down, the liability amount may be withheld from the wrong claim.  This could occur if provider A submits a claim to MHD and provider B does not (either because the bill was paid or it was a non-MO HealthNet covered service).  Since the MHD system can only withhold the participant liability from claims submitted, the liability amount would be deducted from the bill of the provider A.  Provider B's bill may have been enough to reduce the liability to zero, which would have allowed MO HealthNet to pay the provider A's claim.  MHD Participant Services unit will authorize payment of the submitted claim upon their receiving verification of other expenses for that day which would reduce the liability to zero.  Participant Services may request documentation from the case record of bills the county used to meet spend down on the day it was met.  The documentation for that day should be sent to Participant Services.

EXAMPLE: Participant's spend down amount for November is $50.00.  On November 5th, participant goes to a MO HealthNet doctor and is billed for $50.00.  They also incur a $50 expense for a chiropractor visit on November 5th.  Since chiropractor services are not covered by MO HealthNet, this bill will not be submitted to MO HealthNet.  When the doctor bill is submitted to MO HealthNet, nothing will be paid on it as it does not exceed the participant liability for the 5th.  If Participant Services receives verification of the chiropractor expense, MO HealthNet will pay the doctor's bill.

0810. Allowable Third Party Payment from State Funded Programs

IM-#27, March 16, 2012

The Department of Mental Health (DMH) and the Department of Health and Senior Services (DHSS) administer programs that pay spend down participant's expenses until the participant's monthly spend down liability is met. After the participant's liability is met, the providers directly bill MO HealthNet Division instead of the DMH or DHSS.

DMH: The DMH has three Divisions:

Each division operates programs for eligible consumers that provide services through contracted providers. The DMH determines eligibility for these programs.

Division of DD administers five Medicaid Home and Community Based (HCB) Waiver programs for individuals with developmental disabilities under the Social Security Act in 1915(c). The five waivers are the:

Under these waivers, the state provides home and community-based services through Medicaid.

The Division of DD also administers Targeted Case Management (TCM) for Individuals with Developmental Disabilities. TCM is provided by DMH employees, employees of County Boards for Developmental Disabilities (a.k.a. "SB 40" Boards), and employees of other local organizations under contract with the DMH to provide TCM.

Medicaid Home and Community Based (HCB) Waiver services and TCM are not covered by Medicare or other third party insurance. 

The Division of CPS administers Community Psychiatric Rehabilitation (CPR), which provides evaluations, crisis intervention, community support, medication management, and psychosocial rehabilitation to persons with severe, disabling mental illnesses. Division of CPS also provides Targeted Case Management (TCM) for adults with serious mental illness (SMI) and children with a severe emotional disturbance (SED).

CPR, CSTAR, and TCM services are not covered by Medicare or other third party insurance.

NOTE: The amount the provider charges for the services administered by the DMH are allowable incurred expenses to be used to meet the participant's spend down.

DHSS: The DHSS Division of Senior and Disability Services (DSDS) administers the Non-Medicaid Eligible (NME) Personal Care Assistance (Consumer-Directed Model) (CDS) program. NME CDS are provided to persons with a physical disability as an alternative to nursing facility placement. During an assessment, the participant and the Bureau of Home and Community Services (HCS) staff mutually identify unmet needs and determine what services are necessary to meet those needs. NME CDS is provided through the Medicaid State Plan (MSP). The DHSS approves the participant for NME CDS units of care which are included in the care plan established through the DHSS.

The DHSS provides financial assistance for NME CDS through eligible providers, subject to appropriations. All participants of the program must meet the NME CDS requirements set by the DHSS and state law. The DHSS completes an annual review to determine NME CDS participant's continued eligibility.

NME CDS are not covered by Medicare or other third party insurance.

NOTE:  The amount the provider charges for the NME CDS are allowable incurred expenses to be used to meet the participant's spend down.

0810. Identifying DMH Medical Services Allowable For Spend Down

IM-#27, March 16, 2012

The four types of DMH medical services that are not covered by Medicare or other third party insurance and are allowable towards a participant's spend down can be identified through the provider type, designated by the first two digits of the Medicaid provider number.

Each is billed using a provider type that is specific to the services:

A listing of the current Community Mental Health Centers (CMHC) is located at http://dmh.mo.gov/mentalillness/org/adminagents.htm.

A listing of CSTAR providers is located at http://dmh.mo.gov/ada/resourcemapsinfo.htm.

0810. Identifying DHSS NME CDS Participants

IM-#28, March 16, 2012

MO HealthNet (MHN) Program and Policy will provide a listing to the local offices with active NME CDS participants and a copy of their care plan. The listing will include the name of the participant, the provider's name, the participant's DCN, and the CDS units that the DHSS has authorized. The DHSS will notify MHN Program and Policy of any changes in participants, including the addition of new participants or the termination of a participant's eligibility. MHN Program and Policy will then notify the local county office of the change in eligibility for the program.

Each year when the DHSS completes the annual review of their eligibility, the DHSS will send a current copy of their care plan, including any change in their authorized units of NME CDS. If the participant is eligible for a change in units, the DHSS will notify MHN Program and Policy. MHN Program and Policy will then notify the eligibility specialist and supervisor.

0810. Verification of Department of Mental Health (DMH) Medical Expenses to Meet Spend Down

IM-#82, September 20, 2012, IM-#27, March 16, 2012

For medical expenses incurred by an individual receiving Community Substance Abuse and Rehabilitation (CSTAR), Community Psychiatric Rehabilitation (CPR), Developmental Disabilities (DD), or Targeted Case Management (TCM) waiver services paid by the Department of Mental Health, obtain a completed MO HealthNet Spend Down Provider Form or an invoice with all of the following information:

NOTE:  CPR, CSTAR, and TCM are not covered by Medicare or other insurance, therefore there will not be a third party liability identified.

0810. Verification of DHSS Medical Expenses

IM-#28, March 16, 2012

Obtain the following documentation for the DHSS services, not covered by Medicare or other third party insurance, that are allowed as incurred expenses for spend down:

There is not a required format, but it needs to include all of the above information.

The date a medical expense is incurred is the date the individual receives the service, not the date of the bill or the date a bill is paid. The service provided should show CDS. A copy of the care plan is needed to verify the units of care the DHSS has authorized.