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MO HEALTHNET SPEND DOWN PARTICIPANT

Complete the form below and upload all documents to submit medical expenses to be applied to spend down.

Instructions


Complete the chart below with your information and provide proof that the bills were paid, or that you will be responsible for paying.



Please Note:

  • To be acceptable, they must be bills you personally have to pay, meaning they will not be paidby MO Healthnet, Medicare, or other sources.
  • Documentation must include the following details to be used as proof of incurred medicalexpenses: provider name, date of service, type of service provided, total charge, amount paidby third party liability (Medicare/other insurance), and the amount you are responsible to pay.

Month to be Applied and Carryover

All bills will be entered to meet your spend down for the month of service or purchase, unless you choose to apply the expense to a future month. This is called a carryover.

If you have acceptable medical bills from the past 3 months, you can carry them over to help meet your spend down for the current month and/or any of the next 3 months. When you chose to carry over bills from one month (for example, September) to a different month (such as October), you give up the possibility of meeting spend down for the month you carried over from (September).

Example: $250

Example: 9/20/2024

Example: 10/2024, 11/2024, 12/2024

Optional: If you are a Veteran in the state of Missouri and are interested in
learning more about benefits and resources available to you and your
dependents, visit https://mvc.dps.mo.gov/MoVeteransInformation/Survey/DSS.

    Thank You

    Dear {formsubmittinguser},

    Thank you for providing your medical expenses to apply to your MO HealthNet Spend Down. Your information has been sent to the Family Support Division (FSD) for review. You will be notified when we have completed our review. 

    If you did not provide proof of your medical expenses with this form, FSD will not be able to apply the expenses to your spend down amount. If you did not attach the proof, you may submit it at https://mydssupload.mo.gov/UploadPortal.

    If you have questions or want to check on the status of your spend down, you may call FSD Spend Down Unit at 855-600-4412. You can also review our frequently asked questions by visiting: mydss.mo.gov/mhd/spend-down-faqs. Document number {formuniqueid}.

    If you would like to print or save a copy of the Participant Spend Down form for your files, click the Print button below. If you decide to print or save, keep in mind that this form has your private and personal information on it.

    Sincerely,
    Family Support Division