MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION SPEND DOWN NOTIFICATION
FROM	FSD OFFICE	TELEPHONE NUMBER - -	DATE January 24, 2013
FSD OFFICE ADDRESS (STREET)
(CITY, STATE, ZIP CODE)
TO	NAME
ADDRESS (STREET)
(CITY, STATE, ZIP CODE) ,
RE	MO HealthNet Eligible Individual (s):	DCN: 0 0
You recently requested MO HealthNet services. Since your income is over the MO HealthNet limit, your eligibility must be based on a “spend down.” Spend down is similar to a deductible on insurance policies, in that you and/or your spouse are responsible for medical care up to a certain dollar amount before you can become eligible for MO HealthNet coverage. In order to receive continuous MO HealthNet coverage, you can pay your spend down each month, as you would a health insurance premium, to: Premium Payment (Spend down), P O Box 808001, Kansas City, MO 64180-8001. Please see the enclosed pamphlet for additional information.
You have provided medical expenses that meet your spend down for the months listed below. MO HealthNet benefits are active from the start date listed through the end of the month. MO HealthNet will not pay for any bills or portion of bills used to meet your spend down amount. At least part of your spend down amount has been met on the date your MO HealthNet started. *The MO HealthNet Division will deduct the portion of your spend down amount that was met on your MO HealthNet Coverage Start Date from claims submitted for services received on your start date.
MONTH	MO HEALTHNET COVERAGE START DATE	MONTHLY SPEND DOWN AMOUNT	AMOUNT OF SPEND DOWN MET ON START DATE *(Do not send payment to MHD for this amount)
Based on your income, your “spend down” amount is listed below. You have provided proof of countable medical expenses or made a partial payment for the following month(s) but you have NOT met your spend down:
MONTH	SPEND DOWN AMOUNT	ALLOWABLE MEDICAL EXPENSES PROVIDED	PROVIDER NAME	PARTIAL PAYMENT PROVIDED	AMOUNT OF SPEND DOWN EXPENSE REMAINING FOR THE MONTH
You and/or your spouse must have allowable medical expenses in the month that equal or exceed your spend down amount. Allowable medical expenses are limited to the portion of your bills that you are responsible for paying after all third party insurance payments are deducted. MO HealthNet begins counting costs on the first day of the month and adds your medical costs for each day. When the total allowable medical expenses that you are responsible for paying are equal to or exceed your spend down amount, you have “met spend down” for the remainder of the month. You may choose to have allowable medical expenses exceeding your spend down amount for this month applied to future months (up to 3 months) if still owed. If you do not designate a month to apply owed excess medical expenses, the expenses will be applied to the current month. You may not change the month(s) once you have designated it.
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If you meet all other eligibility requirements for MO HealthNet, your coverage begins the day you meet spend down and continues through the last day of the month.
Please provide copies of your paid and/or unpaid medical bills/receipts, doctor bills/receipts, prescription receipts, itemized hospital bills, and other incurred medical expenses or a completed MO HealthNet Spend Down Provider
form to the FSD office by	.	An eligibility specialist will determine which expenses can be
used to meet your spend down. You and/or your spouse may choose to submit the amount of spend down expense remaining for the month to the MO HealthNet Division. If you choose this option you must submit your payment with the Spend Down Payment Option page. (See page 3) and your invoice, if available to: MO HealthNet Division, Premium Payment (Spend down), P O Box 808001, Kansas City, MO 64180-8001.
The following bills were not used to meet spend down:
MONTH	DATE OF BILL	PROVIDER	REASON
If you believe you have medical expenses that have not been considered, please provide documentation of the expense(s) to an FSD office. The legal reason for this decision is found in 42 CFR 435.121; 42 CFR 435.121 (f) (1) (iii) and 13 CSR 70-4.100. If you do not agree with this decision, you have the right to ask for a hearing within 90 days of the date of this letter. To request a hearing, contact 1-855-373-4636 the FSD Information Center (toll free at 1-855-FSD-INFO) or request a hearing by mail or in-person at an FSD office. If you request a hearing, we will schedule it for you and notify you of the time of the hearing. At the hearing, you may present your information yourself or you may ask someone to assist you. You have the right to present witnesses on your behalf and to question witnesses who appear at the request of the Family Support Division. To see if you can get free legal services call: - - . If your situation changes, it is your responsibility under the law to report these changes within ten days of the change to the Family Support Division. The law provides penalties for any persons who receive benefits to which they are not entitled through misrepresenting the facts or not reporting full information about their situation. If you have questions concerning your spend down or MO HealthNet application, contact 1-855-373-4636 the FSD Information Center (toll free at 1-855-FSD-INFO).
ELIGIBLITY SPECIALIST	LOAD	TELEPHONE NUMBER - -
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SPEND DOWN PAYMENT OPTION
Use this section to send in with your payment to MO HealthNet Division, Premium Payment (Spend down), P O Box 808001, Kansas City, MO 64180-8001
Indicate below the amount and month(s) that you would like your payment applied. Failure to indicate a month will result in the
payment being applied to the current month or the first month the payment can be applied to up to three succeeding months.
CASE NAME 0 DCN 0	SPOUSE 0 DCN 0
MONTH	AMOUNT OF SPEND DOWN EXPENSE REMAINING FOR THE MONTH (entry not required)	AMOUNT PAID
TOTAL	$

----------------------------------------------------------------------------Cut Here----------------------------------------------------------------------------------------

Use this section to designate month(s) to apply unpaid/owed medical expenses. You may not change the month once you have designated it. Send this section with your bills to the local FSD office.

CASE NAME 0 DCN 0	SPOUSE 0 DCN 0
AMOUNT OF EXCESS UNPAID MEDICAL EXPENSES	MONTH UNPAID MEDICAL EXPENSES INCURRED	MONTH TO APPLY EXCESS UNPAID MEDICAL EXPENSES TO SPEND DOWN
Signature of Participant or Authorized Representative	Date	Signature of Spouse or Authorized Representative	Date
X	X
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INSTRUCTIONS FOR THE SPEND DOWN PAYMENT OPTION

This page is used when sending a partial payment to MO HealthNet Division or designating months to apply carryover unpaid excess medical expenses.

THE FIRST SECTION IS COMPLETED WHEN SENDING A PARTIAL PAYMENT TO MO HEALTHNET DIVISION.

The case name and Department Client Number (DCN) field: This field is completed with the name and DCN of the head of household on the MO HealthNet case. The DCN is the same as the number on your MO HealthNet card.

The name of spouse of head of household and DCN field: This field is completed with the name and DCN of the spouse on the MO HealthNet case.

MONTH: In this field enter the month and year you want to pay your spend down amount.

AMOUNT OF SPEND DOWN EXPENSE REMAINING FOR THE MONTH: In this field enter the amount of spend down you have remaining for the month you are sending in a payment. This amount is shown on page 1 under “AMOUNT OF SPEND DOWN EXPENSE REMAINING FOR THE MONTH.”

AMOUNT PAID: Amount of payment sent to MO HealthNet Division at Premium Payment (Spend down), PO Box 808001, Kansas City MO 64180-8001

TOTAL: Enter the total amount sent to MO HealthNet Division.

Example: Mr. Jones has a spend down of $500.00, and has incurred bills of $450.00 in June, he would like to pay in the additional $50.00 for June as he knows he will have additional medical expenses that month and wants MO HealthNet coverage to begin.

Month	Amount of Spend down expense remaining for the month	Amount paid
June	$50.00	$50.00
TOTAL	$	50.00

THE NEXT SECTION IS USED WHEN DESIGNATING THE MONTH(S) TO APPLY OWED EXCESS MEDICAL EXPENSES. Mail this section with a copy of your owed bills to your local FSD office.

AMOUNT OF EXCESS MEDICAL EXPENSES: Enter the amount of unpaid medical expenses that exceed spend down amount and are NOT subject to payment by another source.

MONTH UNPAID MEDICAL EXPENSES INCURRED: Enter the month the medical expenses were incurred.

MONTH TO APPLY EXCESS UNPAID MEDICAL EXPENSES TO SPEND DOWN: Designate the month (up to 3 succeeding months) which to apply your owed medical expenses toward your spend down amount.

SIGNATURE OF PARTICIPANT OR AUTHORIZED REPRESENTATIVE: This section is signed by the head of household on the MO HealthNet case, or their authorized representative.

SIGNATURE OF SPOUSE OR AUTHORIZED REPRESENTATIVE: This section is signed by the spouse of head of household on the MO HealthNet case, or their authorized representative.

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