PURPOSE: This rule establishes terminology as well as provides definition of terms for the spend down program and defines valid verification of incurred medical expenses.

1. (1) Spend down is a program created for persons with disabilities and persons aged sixtyfive (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. (2) The following definitions apply throughout this regulation:

   1. (A) Incurred medical expenses: 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 premiums, 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;
   2. (B) Individual: Aged persons (over sixtyfive (65) years), blind persons, or people with disabilities with income above limits established under section 208.151.1.(24), RSMo, for old age assistance benefits, permanent and total disability benefits, or aid to the blind benefits; and
   3. (C) Third party: A third party is Medicare, private health insurance, or other health care payer.
3. (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. (4) Spend down may be met in one (1) of the following ways:

   1. (A) Incurred Costs Method. Spend down participants using this method must provide documentation of medical expenses they have incurred.

      1. 1. Incurred medical expenses that can be

applied to spend down must be either—

1. A. Incurred within the month MO

HealthNet coverage is requested and bills are 13 CSR 40-2

submitted to the Family Support Division; or

1. 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.

1. 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—

1. (I) The bills were incurred while

the participant was eligible for MO Health- Net spend down;

1. (II) The bills were not paid and will

not be paid by MO HealthNet;

1. (III) The bills are currently owed

by the participant;

1. (IV) The bills were not previously

applied in any month to meet spend down, including use of out-of-pocket expenses; and

1. (V) The bills were incurred no ear-

lier than three (3) months prior to the current month.

1. D. Allowable medical expenses

include those specified in section 208.152, RSMo.

1. E. Proof of incurred costs does not

require proof of payment of the incurred costs.

1. 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.

1. 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 of the following methods:

1. A. An invoice, billing statement, or

receipt from the provider that contains the following information:

1. (I) Name of patient;
2. (II) Date of service;
3. (III) Type of service provided

and/or description of the service;

1. (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 patient’s responsibility to pay; and

1. (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

1. B. A Family Support Division

Provider form signed and completed by the provider containing the information set out in subparagraph (4)(A)3.A. of this regulation.

1. 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.

1. 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—

1. A. For individuals with private health

insurance or coverage by another health care payer, estimate the amount of the individual’s incurred cost based upon the provisions of coverage; and

1. 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—

1. (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

1. (II) Twenty percent (20%) of the

Medicare allowable reimbursement once the deductible has been met.

1. 6. Individuals receiving Qualified Medi-

care Beneficiary coverage cannot use incurred medical expenses covered by Medicare towards meeting spend down.

1. 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.

1. (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.
2. (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.

1. (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. 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. *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.