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2.6.3 Claims Filing Involving a Medicaid Spend Down
Clients are responsible for informing their medical providers of their Medicaid eligibility and making arrangements to pay the charges used to meet the spend down amount. For CSHCN Services Program clients, the CSHCN Services Program may consider paying the charges used to meet the spend down for covered services.
The clearinghouse notifies the client of:
• The bills or charges that were used to meet the spend down.
•The bills or charges that the client is financially responsible to pay.
•The bills or charges that the provider should submit to the Texas Medicaid Program for consideration of payment.
Claims for unpaid bills not applied toward spend down or not previously sent to or paid by the CSHCN Services Program, must be received by TMHP for Medicaid consideration within 95 days from the date eligibility was added to the TMHP client eligibility file (add date). These bills must be on the appropriate claim form (such as CMS-1500 and UB-04 CMS-1450).
The client's payment responsibilities are as follows:
•When the entire bill was used to meet spend down, the client is responsible for payment of the entire bill. For CSHCN Services Program clients, submit the bill to the CSHCN Services Program for payment consideration.
•When a portion of one of the bills was used to meet the spend down, the client is responsible for paying the portion applied toward the spend down. For CSHCN Services Program clients, submit the bill to the CSHCN Services Program for payment consideration.
Claims are subject to the following:
•The claim must show the total billed amount for the services provided. Charges for ineligible days or spend down amounts must not be deducted or noncovered on the claim.
•A client's payment toward spend down must not be reflected on the claim submitted to TMHP.
Note: Payments made by the client for services that were not used in the spend down, but were incurred during an eligible period must be reimbursed to the client before the provider files a claim with TMHP.
Once eligibility is established, the client is eligible to receive the same care and services available to all other Medicaid clients.
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