It is the eligibility specialist's responsibility to explore eligibility for and explain the availability of this coverage to each participant.
The eligibility determination for prior quarter MO HealthNet coverage is separate from the eligibility determination for current MO HealthNet coverage. A participant does not have to be currently eligible for MO HealthNet coverage to be eligible for prior quarter coverage.
The prior quarter is the three month period prior to the month of application. Prior quarter coverage can begin no earlier than the first day of the third month prior to the month of the application and can extend up to but not including the first day of the month of application.
The participant must meet all eligibility factors including spend down/non-spend down or vendor, during the prior quarter. If the participant becomes eligible for assistance sometime during the prior quarter, the date on which eligibility for MO HealthNet begins depends on whether the participant is eligible as a non-spend down, spend down or vendor case.
For non-spend down cases prior quarter coverage begins on the first day of the month in which the participant became eligible for assistance.
EXAMPLE: Mr. Blue applies on April 15th. The prior quarter would be the months January, February, and March. He had cash & securities above the available resource maximum until February 3rd. He became eligible on all factors in February. MO HealthNet eligibility begins February 1st.
For spend down cases, the MO HealthNet eligibility date is the first day of the first month of the prior quarter in which the participant was eligible on all factors except meeting spend down. MO HealthNet coverage begins on the first day in which spend down is met in each of the prior months. Each of the three prior month's medical expenses will be compared to that month's spend down separately. The participant may be eligible for one, two, or all three months.
Process new MHABD applications, where the applicant has provided documentation of incurred medical expenses to meet spend down, within normal application processing time frames provided all other eligibility criteria is met. The eligibility specialist cannot enter incurred medical expenses for a prior quarter month on the MSPA screen until the first working day after the approval is entered in FAMIS. Then, the eligibility specialist should complete the MSPA entry of incurred medical expenses that meet spend down if the amount of any third party liability and personal responsibility has been determined.
The eligibility specialist must not wait for the participant to meet the present month's spend down or to meet spend down in any other months of the prior quarter.
EXAMPLE: Ms. Green applies on April 15th. On May 23rd the eligibility specialist determines she was eligible on factors except meeting spend down starting in February, she was ineligible on available resources until February 3rd. Her spend down for each month is $200. She has presented incurred medical expenses for March in the amount of $100 on March 2nd and $150 on March 4th, but no bills for any other month. On the MSPA screen enter the date of service and participant’s liability. MSPA will determine the participant’s liability of $100 on March 4th with an end date of March 31st.