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Spenddowns

Peg LarsonGe Her

Health Care Training

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Session Goal

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Agenda

• Spenddown Types

• Health Care Expenses

• Case Examples

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Spenddown Basics

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Which MHCPs allow a spenddown?

MA

MA payment of LTC Services

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Spenddown Definition

A cost-sharing approach which allows MA eligibility for people whose net countable income is greater then the applicable FPG standard.

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Spenddown Methods

Medical

(Community)

Institutional

(LTC)

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Medical Method(Community)

• MA not requesting LTC

• EW (not SIS) without

a community spouse

• Disability Waivers

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Institutional Method(LTC)

• Residing in LTCF

• EW with community spouse

SIS-EW = Waiver Obligation

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Medical Spenddown Types

Automated Monthly

Manual Monthly

Six-Month (and shortened)

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Automated Monthly Spenddown

• Income - non-varying

• Medical expenses - recurring

• Eligible for certification period

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Potluck Processing

May spenddown = $ 659

• $400 dental bill from 05/03 Rejected

• $300 RX from 5/11

• $159 Doctor visit from 05/10 Rejected

$100 Rejected

$200 Paid

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Manual Monthly Spenddown

• Income – any• Medical expenses – any• Eligible for certification period• Coverage is intermittent

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Manual Monthly Processing

HRF HRFCoverage Eligible

Coverage Ineligible

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Six- Month Spenddown

Six-Month• Income – all

• Medical Expenses – all

• Eligible with coverage for remainder of certification period

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Six-Month Spenddown Example

$649 $1298 $1298 $1947 $1298 $1298

6 month income $7788

6-month FPG - $6846

6-month spenddown $ 942

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Six-Month Spenddown Example

$100 Dentist bill 4/10

$542 Doctor bill 4/29

$800 ER bill 5/2

6-month spenddown $ 942

Reject $300

Pay $500

Reject

Reject

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Shortened Spenddown

• Six-month spenddown is interrupted

• New household member added in middle of certification period. New person has a multi-month spenddown.

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Shortened Spenddown Amount Calculation

Countable net income for # of months

– FPG for # of months

Shortened Spenddown Amount

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Shortened Spenddown Example

$649 $1298 $1298 $1947 $1298 $1298

FS ER

4 month income $5192

4-month FPG - $4564

shortened spdn. amt. $ 628

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Shortened Spenddown Example

$100 Dentist bill 4/10

$542 Doctor bill 4/29

$800 ER bill 5/2

Shortened spenddown $ 628

Pay $800

Reject

Reject $528

Pay $14

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Medical Expenses

• Verification

• Types of Expenses

• Applying Expenses

• STAT/BILS

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Verifications

Verify all medical expenses!

• Date service was incurred

• Cost of service

• Amount paid

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Expenses Not to Use

• Paid, or should have been paid, by a MHCP

• Previously used to meet a spenddown

•Food cost or home expenses

•Do not directly benefit the client

•Late fees or interest

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HaMPeR

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Bills

• Must be incurred• Client responsible for

• Deducted the month incurred

• Enter separately on STAT/BILS

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Bill 6-Month Spenddown Example

Sanjay applies June 29.

•Requests 2 months retro. • Incurs a $200 health insurance premium on the 3rd of each month.

•Processing July 5.

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Bill 6-Month Spenddown Action

$200 $200 $200 $200

$800 applied on April 1

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Bills - “Moldy”

Old, unpaid medical expenses incurred prior to the certification period

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Bills

• Document amount used on bill

• Apply on the 1st day of spenddown period

• Verify unused portion of bill at renewal

• Deduct paid amount from net bill after spenddown deducted

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Bill Example

$3000 M bill

-$1000 Spenddown deduction

$2000 M bill remaining

-$1500 Paid amount

$ 500 Remaining amount

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Bills - “Peculiar”

• Non-reimbursable

• Paid or unpaid

• Incurred during the certification period

• Applied after H and M bills on the first day of month incurred

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Bills - Examples

• Non-reimbursed access services• Dependent or other relative medical

expenses• MA, GAMC and MCRE co-payments• Remedial Care expenses• Alternative Care costs

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Bills – 5 conditions

• Medically necessary

• Prescribed or recommended by physician or dentist

• Directly benefits client

• Available through medical provider

• Not reimbursed

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Bills

• Paid or unpaid

• Incurred during the certification period

• Reimbursable

• Applied on date of service after H, M and P bills

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Certification Periods and Expense Types

3 4 5 6 7 821 9 10 11 12

Certification Period

H, P and R BillsM Bills

3 4 5 6 7 821 9 10 11 12

Certification Period

H, P and R BillsM Bills

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Why do we care if expenses are recurring?

Helps to determine if an auto-monthly spenddown can be used.

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What are anticipated medical expenses?

Expenses that can reasonably be expected to be incurred in the

future.

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Why do we care about anticipated medical expenses?

Allows us to anticipate the monthly spenddown will be met so that we can approve continued eligibility.

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What are actual medical expenses?

Expenses that have already been incurred.

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Why are actual expenses important?

Can be used to meet all types of spenddowns.

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MAXIS and Spenddowns

1. No spenddown2. Spenddown not met3. Six-month spenddown4. Automated monthly spenddown5. Manual monthly spenddown

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Case Examples

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Case Scenario 1A

Spenddown Type?

Insurance Premium?

Prescription Costs?

Vitamins?

H Bill

Auto-Monthly

R Bill

P Bill

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Case Scenario 1BSpenddown Type?

Insurance Premium?

Prescription Costs?

Vitamins?

Unpaid dentist bill?

H Bill

Manual Monthly

R Bill

P Bill

M Bill

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Case Scenario 1C

Spenddown Type?

Insurance Premium?

Prescription Costs?

Paid hospital bill?

Unpaid dentist bill?

H Bill

6- Month

R Bill

R Bill

M Bill

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Case Scenario 2A

Spenddown Type?

Insurance Premium?

Paid Dental Bill (T)?

Unpaid Hospital Bill?

Unpaid Dental Bill (K)?

H Bill

Manual Monthly

P Bill

M Bill

R Bill

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Case Scenario 2BSpenddown Type?

Insurance Premium?

Prescription Costs?

Paid hospital bill?

Unpaid dentist bill?

H Bill

Manual Monthly

R Bill

N/A

M Bill

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Case Scenario 2C

Spenddown Type?

Unpaid dentist bill?

6- Month

M Bill

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Case Scenario 3A

Spenddown Type?

Prescription costs?

Unpaid ER bill?

6- Month

R Bill

M Bill

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Case Scenario 3B

Spenddown Type?

Prescription costs?

Unpaid hospital bill?

Manual Monthly

R Bill

R Bill

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Case Scenario 3C

Spenddown Type?

Prescription costs?

Paid contact lenses bill?

Auto-Monthly

R Bill

P Bill

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Resources

POLI/TEMP –

HCRW (Health Care Rewrite)

HCPM Chapter 24

MMIS User Manual

Health Quest

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Spenddowns are your friends!