The pay-in option allows participants to meet their spend down obligation by making a monthly payment of their spend down amount to the State, much like paying a monthly health insurance premium. They have two options to pay-in their spend down. They must choose only 1 option. Participants will have coverage for the whole month that they pay for.
MO HealthNet Division
P.O. Box 808001
Kansas City, MO 64180-8001
The participant must put their MO HealthNet number (case number) on the check or money order. They should mail their payment along with the invoice stub for the month for which they are paying. If they do not have the correct invoice stub to send, they must write on the check or money order what month they are paying for. They must not send an old invoice to pay for a current month.
Participants who pay-in will have continuous coverage as long as payment is received prior to the first day of the month for which they are paying. When a participant pays in, MHD will create a coverage period on the MSPI screen that begins on the first day of the month for which the participant is paying. If the participant pays for the next month prior to the end of the current month, there will be no end date on the coverage period. If a payment has been missed, the MSPI screen will show the coverage dates with an end date of the last day of the month for which MHD received payment.
As long as the case remains open, a participant may pay-in retroactively for any month up to twelve months after the invoice for that month was sent. If the payment is received after a month has ended, the MHD will create a coverage period on MSPI beginning the first day of the month and ending the last day of the month.
If a participant does not have MO HealthNet claims paid that equal or exceed the spend down amount that they paid for that month, the difference will be refunded to the participant thirteen months later. It takes thirteen months for MHD to process the refund because providers may bill MO HealthNet for twelve months from the date of service.
The first month the participant has the option to pay-in is the month of approval. The approval letter, FAMIS form FA-460 MO HealthNet Action Notice, will instruct the participant to submit bills to the eligibility specialist for MO HealthNet coverage for any months of prior quarter eligibility. MHD will send all new participants separate invoices for the month of approval and the month following approval that gives the participant the option of paying-in or sending bills to the eligibility specialist for those months.
Participants will be given the option of filing a form with MHD to have their spend down amount withdrawn from an existing bank account. Withdrawals will be made on the 10th of each month. The participant will receive a monthly notification of withdrawal from MHD. If a problem with the withdrawal occurs, MHD will send a letter informing the participant that their Automatic Withdrawal was returned. Reasons for the return and instructions on how to resume or correct the problem are included in the letter.
Some agencies, such as Department of Mental Health, may choose to pay the spend down amount for some of their clients. Agencies interested in this process will work with MHD to identify participants for whom the agency will pay the monthly premium. The MSPI screen will show what agency paid the spend down for the participant and will show these participants as having continuous coverage due to pay-in by the agency.
Participants may combine incurred medical expenses and partial pay-in of a MHD invoice amount to meet spend down in one of the following ways:
NOTE: Incurred medical expenses can be carryover and/or current expenses. See Section 0810.010.15 Meeting Spend Down with Incurred Expenses.
Participant Submits Bills Prior to Submitting Payment
When a participant sends incurred expenses to the local FSD office that do not meet their spend down liability, the eligibility specialist (ES) determines the remaining spend down liability and sends the participant the Spend Down Notification (IM-29(SPDN)) form to inform the participant that they need to provide additional bills or partial pay-in to meet spend down. If they choose to mail a partial payment to the MHD Premium Collections, the participant should include the IM-29 (SPDN) Spend Down Payment Option page and their invoice, if available.
If a participant makes a partial payment for the same month that the medical expenses are incurred, spend down coverage starts from the last date of service when total expenses plus partial payment meets the spend down amount.
If there are carryover incurred expenses from the prior three months combined with partial payment, spend down coverage starts on the first date of the month coverage is selected by the participant.
Participant Submits Payment Prior to Submitting Bills
If the participant sends partial payment to the MHD Premium Collections, the partial payment is held for 60 days from the last day of the month the payment is received. MHD will notify the MO HealthNet (MHN) Program and Policy to determine if incurred medical expenses have been submitted.
Processing Partial Payments
MHD will send a notice to MO HealthNet (MHN) Program and Policy that a partial payment has been received including:
MHN Program and Policy corresponds with the local FSD office to determine if incurred expenses have been received and the start date of coverage.
MHN Program and Policy enters spend down liability and date in MO HEALTHNET DIVISION ADD spend down COVERAGE (MSPA) screen and updates the Method field code in MO HEALTHNET DIVISION spend down UPDATE (MSSU) screen to "O" for other, and notifies MHD to process the payment.
MHN Program and Policy notifies the local FSD office to send an IM-29(SPND) form to the participant notifying them of the date spend down was met.
EXAMPLE: Mr. Brown has a spend down liability of $300. He incurs a $200 dentist bill on August 7th and knows that he has a future surgery in the same month. Mr. Brown does not want to wait for the bills from his surgery in order to activate his spend down. Mr. Brown provides his $200 dentist bill to the ES and then sends the remaining $100 he owes with the IM-29 (SPND) Spend Down Payment Option page to MHD. After MHD receives the payment, Mr. Brown's coverage begins on August 7th.
| MONTH | SPEND DOWN LIABILITY | COUNTABLE MEDICAL EXPENSES | PAYMENTS TO MHD PREMIUM COLLECTIONS |
|---|---|---|---|
08/2012 |
$300 |
$300-$200 Incurred Expenses = $100 |
N/A |
08/2012 |
$300 |
N/A |
$100 - $100 Payment (Applied to August) |
EXAMPLE: Mrs. Collins has a spend down of $1200. She incurred expenses of $500 in July, $200 in August, and provides these bills to the local FSD office on September 3rd. On September 8th, MHD receives a partial payment of $500 from Mrs. Collins with her September invoice. The ES will receive notification from MHN Program and Policy indicating a partial payment has been received by MHD. The ES contacts MHN Program and Policy to enter the bills for her September spend down. MHN Program and Policy will then notify MHD to apply the partial payment to September. Her spend down for September is met on September 1.
| MONTH | SPEND DOWN LIABILITY | COUNTABLE MEDICAL EXPENSES | PAYMENTS TO MHD PREMIUM COLLECTIONS |
|---|---|---|---|
07/2012 |
$1200 |
$1200-$500 = $700 (spend down not met) |
None |
08/2012 |
$1200 |
$700-$200 Incurred Expenses = $500 (spend down not met) |
None |
09/2012 |
$1200 |
N/A |
$500 Payment (Applied to September combined with July and August carry over expenses meets spend down) |
Senate Bill 577 (2007) amended Section 208.153 RSMo to allow a reduction in spend down for up to three months for a participant who paid a spend down invoice and then pays an eligible out-of-pocket medical expense in the same month. As of January 2008, if a MO HealthNet participant pays-in his or her invoiced spend down amount for the month and also pays eligible out-of-pocket medical expenses in the same month, the amount of the out-of-pocket medical expenses may be applied to reduce the amount owed on unpaid invoices for up to the next three months from the date of the expense. If the out-of-pocket expense exceeds the total of three month's invoices, or if the documentation of the paid out-of-pocket expense is not received in time to apply it to the three month period following the date of the expense, the participant may not receive the benefit of the out-of-pocket expense reduction.
NOTE: When discussing PAID-IN spend down and out-of-pocket expenses with participants, explain that it is to the participant's advantage to submit documentation of the paid expense in the same month the service is received and paid.
When a participant provides documentation that they have paid out-of-pocket medical expenses, within two (2) business days from receipt of documentation the eligibility specialist must view the MO HEALTHNET DIVISION PREMIUM INQUIRY SCREEN (MPNI) to verify the participant paid-in their spend down for the month for which bills for out-of-pocket medical expenses are submitted and determine if the payment was for an eligible medical expense.
When it is verified that the spend down was paid-in and there was an eligible paid medical expense:
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 IN 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 1-877-888-2811.
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.
Participants who have automatic withdrawal (Electronic Funds Transfer (EFT)) of their spend down premium payment will continue to have the full invoiced amount deducted from their account less any out-of-pocket expenses entered on MSPO for that invoiced month. If the participant pays an eligible medical expense in the same month that their spend down payment was automatically withdrawn, the above process for entering out-of-pocket expenses should be followed. The next month's invoiced amount will adjust and only automatically withdraw the adjusted amount after the eligible out-of-pocket expenses have been applied. MHD will not issue refunds to the participant.
A spouse's expenses can be used to meet spend down; therefore, a spouse's out-of-pocket expenses can also be used to reduce the next 3 invoices. However, MSPO entries to reduce the next 3 invoices can only be entered under the head of household that the invoice was issued to and displayed as paid on MPNI.
When it is determined the participant did not did not pay for an eligible medical expense the eligibility specialist will:
Do not send the IM-29OPE for ineligible medical expenses to the ES supervisor or the regional policy liaison.
EXAMPLE: Mrs. Moore paid her September 2011 spend down invoice of $158. On January 5, 2012, Mrs. Moore provided some documentation to the eligibility specialist that she wanted to apply to out-of-pocket expenses. The documentation provided was an explanation of benefits from the participant's Part D plan dated 9/2/2011, which stated what the "plan paid" and what you paid", in addition to "other payments made by programs or organizations." There was no accompanying verification from the pharmacy used to indicate that participant had actually paid the co-pays.
This is not an eligible out-of-pocket request for two reasons which the eligibility specialist recorded in the appropriate section of the IM-29SPDN:
EXAMPLE: Mrs. Plano paid her October 2011 spend down invoice of $136. On January 06, 2012, Mrs. Plano provided some documentation to the eligibility specialist that she wanted to apply to out-of-pocket expenses. The documentation provided was a statement from her doctor's office which indicated a balance due of $21.19. The itemization indicated the $21.19 expense was from a date of service 05/13/11. There was additional itemization reflecting charges of $95 on 10/14/11, an adjustment of $27.95, and a payment of $67.05.
These are not eligible out-of-pocket expenses for the following reasons, which the eligibility specialist records in the appropriate section of two separate IM-29OPE forms. Two IM-29OPE forms are required as it is two different services dates in different 3 month periods.