Spend Down Update

April 4, 2013
Home Health Issue: Some FSD offices were requiring home health providers to submit the physician order, or plan of care (485) along with the bill for private services delivered during the time the patient is not receiving MO HealthNet benefits (not active on Medicaid-during their spend down period). If you are providing private pay home health services to a patient, under a physicians order (as is required for all home health care) the invoice for your services, along with the attestation form available at: https://dss.mo.gov/fsd/massist.htm (then go to the little box on the right hand side under Spend Down and click on the attestation statement), is sufficient to be counted towards the patient’s spend down. Pay-In Option to meet Spend Down: Patients who choose to pay their spend down amount at the beginning of the month are NOT to send the payment to the local FSD office. Below are the rules for pay-in: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. Option 1:Participants may send a payment (check, money order, or cashier’s check) to the MO HealthNet Division. Participants may mail spend down payments to:
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. Option 2: Participants may have their payment taken directly out of their bank account on the 10th of each month by the MO HealthNet Division to pay for their spend down obligation for the following month. To have their payment automatically taken from their bank account the participant must complete the Spend down Automatic Withdrawal Form. They must allow 30 days for the automatic withdrawal to process. The participants cannot use bills to meet their spend down if they chose to have the payment taken from their bank account each month through automatic withdrawal. If the participant has insufficient funds to cover the automatic withdrawal, they must send either a money order or cashier’s check to cover the insufficient payment.

If the participant changes banks or changes accounts within their bank, they will need to submit a new automatic withdrawal form (https://dss.mo.gov/mhd/participants/pdf/awa-spenddown.pdf) marked “change,” and will need to allow 30 days for this change to take place. Amounts and Submission of Invoices for private pay services delivered when the recipient is not receiving MO HealthNet benefits (not active on Medicaid) to meet Spend Down: The invoice/bills may be submitted by the provider on behalf of the patient or by the patient directly. Home Health services may be billed to the patient at the agencies usual and customary (private pay) rate (for the same service). CDS and Personal Care services authorized by the Department of Health and Senior Services are allowed to meet spend down but must be billed at the state rate (the Medicaid reimbursement rate for the service). Personal care services that are not authorized by the Department of Health and Senior Services but are medically necessary as prescribed by a physician are allowed to be billed at your usual and customary (private pay) rate. However, you must submit the physician’s order for these services along with the invoice/bill that is submitted to FSD. FSD will review each of these cases and consult with DSDS when necessary. Documenting in-home tasks/time: If you are providing personal care to a DSDS in-home or CDS client on a private pay basis at the beginning of the month during the period of time that the client has not met spend down, you do not have to document every task (5 minutes to brush teeth, 20 minutes to help with bathing, etc.). You may bill for the hour(s) of personal care authorized and delivered. Obviously you can only bill for a service that you provided and for the amount of time it takes (in total) to deliver. So if you were providing 2 hours of personal care and during those two hours you provided assistance with bathing, toileting, meal prep, etc. you do not have to list each of the tasks you provided just list that you provided 2 hours of personal care, the date, the worker, etc.

Who Can Pay for Medicaid Spend Down?

August 21, 2012
What is a Medicaid spend down? Medicaid, also known as Title XIX, or MO HealthNet in Missouri, is a medical assistance program for low-income people who are elderly (65 years and older), permanently and totally disabled, blind or who meet some other category of eligibility. Some people have so little income that they automatically qualify for Medicaid. However, seniors and people with disabilities, whose incomes exceed the income limit, may qualify for Medicaid if they have “incurred” medical bills that equal or are greater than their “excess” income. The process of subtracting those medical bills from the individual’s income is called “spend down.” For example, a person over 65 is determined eligible for MO HealthNet benefits, but her monthly income exceeds the income limit for MO HealthNet non-spend down by $50. If she incurs medical bills of $50 in a month, the rest of her medical bills will be covered by MO HealthNet until the end of the month. The spend down in this case is the $50 of medical bills she incurs. Who can get spend down? Not everyone. A person must be permanently and totally disabled, blind or at least 65 years of age, have assets of no more than $4,000 if single, or $8,000 if married, and have income which exceeds the Medicaid limit in order to qualify for MO HealthNet spend down. Eligible people living in their own home, apartment, senior housing, congregate housing, etc. are eligible to be placed on a spend-down if they have income over the Medicaid limit. Individuals who are ineligible for vendor or HCB level of care due to a transfer of assets may be eligible for spend down. Individuals with income exceeding HCB income limit, currently $1,370 (changing to $1,388 in January 2021), may be eligible for spend down. How does spend down work? When you have incurred medical bills greater than your excess income, you will receive MO HealthNet coverage from the date you have incurred medical bills equal to or exceeding your spend down amount to the end of the month.. You are responsible for the bills up to the excess amount; MO HealthNet will only pay those bills over the excess amount. Title XIX also permits a State to have a program whereby an individual “pays in” his or her spend down requirement to the State (almost in the nature of a premium). This option, set forth in Section 1903(f)(2) of the Act, permits an individual to pay his or her spend down amount — i.e., the difference between their income and the medical assistance income level — to the State. If the State chooses to establish a pay-in program, as Missouri has, individuals may have a choice between the pay-in option and incurring expenses that will qualify them for MO HealthNet coverage for the month. What types of medical expenses count toward spend down? The bills must be ones which the participants owe for medical services or items for themselves or their spouse if their spouse’s income is counted in the spend down determination, which no other insurance or program is going to pay, for necessary medical 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 such as Department of Mental Health or Department of Health and Senior Services. Only expenses included in Section 208.152, RSMo can be used to meet spend down. In this section, personal care services are allowed at the state rate; this applies to all charges for personal care services including home health agencies. To “incur” an expense means to be personally responsible to pay for the expense. The Centers for Medicare and Medicaid Services (CMS) Handbook clarifies that the only medical expenses that may be allowed to meet a participant’s monthly spend down are those charges for which the participant is personally responsible. If a participant has a monthly spend down of $300, he/she must personally be responsible for $300 in medical expenses each month before his/her spend down is met. Third Party Payments for Spend-down Can third parties (specifically, providers) pay the spend-down amount to the State? The answer is no. The rules governing incurred expenses state that expenses must be “incurred by the individual or financially responsible relatives, and are not subject to payment by a third party” (unless the third party is a program of the State or one of its subdivisions). The problem with having a provider pay the spend-down amount is that, from CMS’s perspective, the Medicaid applicant’s income remains above the medical assistance level, because he or she has not incurred or paid expenditures that bring his or her income down to the Medicaid level. CMS therefore considers individuals whose spend-down has been paid by a third party not to be Medicaid eligible because he or she may not meet the spend-down requirement. Note that this is not a problem if the spend-down payment is made by a financially responsible relative on the individual’s behalf or if it’s made by a program of the State or one of its subdivisions. In either of those cases, the payment is treated the same as if it had been made by the individual. In the above situation, Medicaid could not reimburse the provider for the incurred expense, as that is the responsibility of the individual. Medicaid rules provide that “[e]xpenses used to meet spend- down liability are not reimbursable under Medicaid.” 42 C.F.R. 435.831(h)(5). Therefore, “[t]o the extent necessary to prevent the transfer of an individual’s spend-down liability to the Medicaid program, States must reduce the amount of provider charges that would otherwise be reimbursable under Medicaid.” Id. Documentation required for spend down. MO HealthNet Eligibility Specialists must obtain documentation of incurred medical expenses. This documentation will be reviewed to determine the accuracy of the invoice or billing statement. How much is spend down amount? The amount of spend down is the extra income that is over the limit to receive Medicaid automatically. The Family Support Division figures out this amount for each person, taking into account the person’s income and living arrangements. Currently the Net Income limit for Elderly and Disabled is 85% of the federal poverty level (Individual – $904, Couple – $1,166). The Net Income limit for Blind is 100% of the federal poverty level (Individual- $1,064 Couple-$1,472). The federal poverty level is adjusted annually. How often does a MO HealthNet participant have to meet spend down? The participant will have to meet the spend down every month unless his/her income and living arrangements have changed so much that he/she qualifies for MO HealthNet without a spend down. To receive MO HealthNet coverage in any month, the participant has to meet the spend down first. How do you know if you qualify for spend down? If you have been denied full coverage under the MO HealthNet for Aged, Blind and Disabled program, the notice MO HealthNet must send you will tell you if you qualify for spend down and, if so, the amount of your monthly spend down.