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Missouri changing rules for Medicaid 'spend down' plan

Sunday, February 26, 2012 | 6:27 p.m. CST

JEFFERSON CITY — Some low-income seniors and people with disabilities in Missouri could have to pay more out of their pockets to qualify for Medicaid coverage under changes being initiated after the state realized it was running afoul of federal rules.

About 24,000 Missouri residents qualify for Medicaid — even though their income is higher than the program's federal limits — by "spending down" the difference between their monthly income and the federal eligibility limit. They do that in one of two ways — sending the state a cash payment, sort of like a monthly insurance premium, or by submitting medical bills that show they spent that excess income on medications and treatments.

About one-third of the people in the program submit medical bills to satisfy their monthly "spend down" amount.

The problem, as state officials told a Senate panel this past week, is that the state might have been giving people too much credit toward their monthly "spend down" amount.

Alyson Campbell, the director of the Department of Social Services' Family Support Division, told lawmakers that, in some cases, department staff had been incorrectly giving credit for the full amount of a person's medical bill — even if parts of it were paid for by Medicare or private insurance or were written off altogether by the person's medical provider. That means some people in the program might have received Medicaid coverage for which they were not truly eligible.

Federal law says that people in the program are only supposed to receive "spend down" credit for the portions of the medical bills that they actually pay.

Campbell said the department contacted federal regulators about the problem late last year and is still trying to figure out how many claims were handled incorrectly.

The department is also trying to figure out whether Missouri owes the federal government any money for paying Medicaid benefits to people in the "spend down" program who actually hadn't met their monthly amount. She said some people might have incorrectly qualified for Medicaid coverage, but were never paid any benefits.

Department of Social Services Interim Director Brian Kinkade said that people who joined the "spend down" program after Feb. 1 will have their bills processed per the federal rule.

But people who were in the program before that date could continue to receive credit for the full amount of their bills, at least until May. That way, patients who are in months-long treatment programs have time to figure out whether they will lose their Medicaid coverage and make necessary changes to their treatment regimen. Kinkade said federal Medicaid regulators are backing the plan.

"Their concern was with a person who had been relying on a course of treatment, that changing something midstream might be detrimental," he said.

Sixty-six-year-old Carole Crutcher, of Kirkwood, said she's frustrated with the program's changes.

Crutcher, a retired state worker, said she's been submitting medical bills to the state for about four years for treatments for heart and eye problems.

She said her bills for February, for example, have so far totaled $2,000, meaning she's covered her $276 monthly "spend down" amount for Medicaid coverage. But she said portions of those bills are written off by hospitals and covered by Medicare.

Crutcher said she received a letter at the beginning of the month explaining that DSS would soon begin processing her bills per the federal law. She said the department also changed the staff member who deals with her claims and that she was confused by the new person's explanation of the policy.

"It's so totally different than what they had been doing," she said. "I'm worried that I'm going to have quite a time getting them to see that I met my 'spend down' every month."


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