Preventing Medicaid Payment of Expenses Used to Meet Spenddown

PURPOSE: This rule establishes the basis on which the Medical Assistance program may reimburse for Title XIX services after spenddown has been met. Spenddown is a process by which aged persons (over sixty-five (65) years), blind persons, or people with disabilities become Medicaid eligible based on their incurred medical expenses when they would not otherwise be eligible. (1) Aged persons (over sixty-five (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, as amended, are allowed to deduct from income incurred medical expenses (that is, spenddown) to become eligible. (2) Spenddown eligibility shall be calculated on a monthly basis. (3) The MO HealthNet program (Medicaid) will only reimburse enrolled Medicaid providers for covered medical expenses that exceed a recipient’s spenddown amount. Medicaid does not pay the portion of a claim used to meet the applicant’s spenddown obligation. For example, for the first day of coverage, the MO HealthNet Division denies or splits (partially pays) a claim or claims until the applicant’s spenddown liability is reduced to zero (0). (4) After the MO HealthNet Division has reduced the participant’s liability to zero (0) for the first day of coverage, other claims submitted for that day of spenddown coverage and claims for the time remaining in the month are paid up to the Medicaid rate. (5) Participants shall have the option to pay their monthly spenddown requirement to the MO HealthNet Division, much like a premium payment, in order to have continuous Medicaid coverage. Participants may also arrange to make the monthly spenddown payment through electronic funds transfer (EFT) from a bank account. AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.151, RSMo Supp. 2021.* Emergency rule filed April 25, 2005, effective May 5, 2005, expired Oct. 31, 2005. Original rule filed April 29, 2005, effective Oct. 30, 2005. Amended: Filed Jan. 7, 2022, effective July 30, 2022. *Original authority 208.151, RSMo 1967, amended 1973, 1981, 1982, 1987, 1988, 1989, 1990, 1991, 1993, 1995, 2001, 2005, 2007, 2011, 2013, 2018, 2019, 2020; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.