Out-of-Pocket Expenses For Spend Down Cases
See: 3.8.9 Out-of-Pocket Expenses for Spend Down Cases
REQUIREMENT:
A participant’s spend down amount may be reduced for up to three months if he/she has paid a spend down monthly invoice and then paid an approved out-of-pocket medical expense in the same month.
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.
VERIFICATION:
- HC – Documentary evidence of the out-of-pocket expense is required to reduce a participant’s spend down amount.
- Apply the approved expense to the next month’s spend down.
- If there is a remaining balance, apply it to the next month’s (second month) spend down amount.
- Finally, if there is still a remaining balance, apply it to the third month’s spend down.
Example:
Mr. Harrison pays his $120.00 monthly spend down amount directly to MO HealthNet Division. He paid his May spend down on April 20th. Mr. Harrison reported that he paid out-of-pocket vision expense of $260.00 on May 7th and provided a copy of this bill. Mr. Harrison has not sent in his payment for the invoice for the month of June. Mr. Harrison’s out-of-pocket expense is applied to June for $120.00, July for $120.00 and August for $20.00 leaving a balance due for August of $100.00. Complete the Out-of Pocket Expense Form (IM-29OPE) to show the expense applied for the following 3 months, and notify Mr. Harrison that he has met his spend down for June and July and that he has provided $20.00 in medical expenses leaving $100.00 remaining spend down for the month of August.