MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION MO HEALTHNET SPEND DOWN DISCUSSION CHECKLIST

PARTICIPANT(S) NAME(S):	DCN:	DATE:
DCN:

I have informed the participant that his/her monthly spend down or pay in amount is $__________and have explained how

he/she may spend down his/her income.

I have informed the participant of the options for meeting spend down: (1) Pay-In (2) incurred eligible medical expenses

(3) Carry over unpaid incurred eligible medical expenses (4) combination of incurred eligible medical expenses and partial

payment and explained the advantages and the disadvantages.

I have discussed with the participant his/her usual or anticipated monthly medical expenses (i.e. – regular treatments, medical

equipment costs, prescriptions, etc.)

I have discussed the participant's estimated monthly out of pocket expenses.

I have explored other MO HealthNet Programs with the participant: HCB, QMB/SLMB, and Title 1619.

Mr. /Mrs. /Ms. _________________has chosen ____HCB ____QMB ____SLMB1____SLMB2____ Title 1619

Mr. /Mrs. /Ms. _________________has chosen ____HCB ____QMB ____SLMB1____SLMB2____ Title 1619

I have discussed other health coverage my participant has, such as Medicare Part A, B, C, D, supplemental insurance, dental

insurance, vision insurance, Mo Rx plan, and/or reduced prescription plans.

I have determined if the participant has met his/her deductibles for other coverage (Medicare or private insurance).

Amount of deductible____________, and date deductible met__________________.

I have determined the co-pays the participant pays for other insurance including Medicare.

Medicare A________ Medicare B________ Medicare C________ Medicare D________ Private Insurance________

I have explained the definition of incurred expenses and acceptable verification requirements if the participant chooses to

incur expenses.

I have reviewed the methods of payment if the participant chooses to pay-in the spenddown or submit partial payment and

informed the participant that the local office does not accept these payments, and the payment center does not accept cash.

(The Automatic Withdrawal Authorization or Change form has been completed, if the customer chose this option.)

I have entered comments to support my discussion with the participant on EUMEMROL in FAMIS and have filed

necessary hard copy documentation in the record, if any.

I have given the participant any pamphlets that are appropriate for his/her situation, such as QMB, MEDICAL ASSISTANCE

SPEND DOWN, MoRx, etc.

NOTES:

CUSTOMER SIGNATURE:_________________________________ES SIGNATURE___________________________________

MHN 07/12

MHABD SPEND DOWN DISCUSSION CHECKLIST INSTRUCTIONS

This form provides a format to discuss spend down information with the participant in- person or by telephone contact. If it is completed in-person, the participant and the interviewer should sign the form. If it is completed by phone, the interviewer will sign the form and enter "by phone" on the customer’s signature line. The form may be used for updating the participant's record or when completing a case review. If this form is completed it should be filed in the participant’s case.

Instructions for following questions and/or statements:

Discuss the budget used to determine the participant's spend down amount with an overview of what spend down means. The amount of spend down.

The four options for meeting spend down and explained the advantages and the disadvantages.

Discuss participant's usual/regular monthly medical expenses.

Explain "out-of-pocket" expenses and how utilized.

Check mark possible program(s) the participant may be eligible.

Discuss all TPL coverage participant receives.

Discuss TPL deductibles and if they have been met.

Enter the amounts of each co-pay the participant pays for each TPL.

Clarify what incurred expenses are and what the participant needs to send in for verification, if they choose to meet their spend down with bills.

Discuss spend down payment methods, pay-in and partial payment.

Enter comments that are clear, concise, and easily interpreted by anyone reviewing the case. The spend down option the participant has selected should be clearly stated in the comment.

Circle type of pamphlet given to participant. (Specify other if the pamphlet is not listed.)

NOTES: Enter any comments or notations not addressed on checklist which is relevant to case.

Have the customer sign, if in-person interview. Write "by phone", if a phone interview.

If clarification is needed, use normal supervisory channels to submit an IM-14 to Program and Policy.