PURPOSE: This amendment updates the terminology for
the spend down program and defines valid verification of incurred medical
expenses.
(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; and
(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 HealthNet 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 subpara-graph (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
13 CSR
40-2.395
AUTHORITY: section
207.020,
RSMo 2000, and sections
208.151,
208.153,
and
208.201,
RSMo Supp. 2011.* Original rule filed March 1, 2012, effective Oct. 30, 2012.
Amended by
Missouri
Register April 1, 2019/Volume 44, Number 7, effective
5/31/2019
*Original authority: 207.020, RSMo 1945, amended 1961,
1965, 1977, 1981, 1982, 1986, 1993; 208.151, RSMo 1967, amended 1973, 1981,
1982, 1987, 1988, 1989, 1990, 1991, 1993, 1995, 2001, 2001, 2005, 2007, 2011;
208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007; and 208.201,
RSMo 1987, amended 2007.