KEYNOTES FOR

SPENDDOWNS

Debbie MillerChartoya NewtonOctober 1, 2015

What is a Spenddown?

A spenddown results when countable income exceeds the Medically Needy income limit. A spenddown works like an insurance policy deductible. The amount of the “deductible” is called the “spenddown liability.” The spenddown process allows the customer a second chance to become eligible for full Medicaid coverage once they have enough medical expense deductions.

THE SPENDDOWN OVERTUREM1310

How many Medicaid covered group classifications are there?

M0310.001

The Medicaid covered groups are divided into

two classifications:

The categorically needy (CN) and the medically needy (MN).

CN individuals meet all Medicaid non-financial requirements (see M02) and the definition for a covered group. MN individuals meet all Medicaid non-financial requirements and resource requirements, but have income in excess of the Medicaid limits.

MN individuals may be placed on a spenddown (SD). The covered groups are also divided into Aged, Blind and Disabled (ABD) and Families & Children (F&C) covered groups.

Spenddown Requirements for ABD and F&C

Spenddown applies only to medically needy (MN) covered groups (M0310.002 B).

Individuals and families must meet the MN nonfinancial and resource requirements in order to be placed on a spenddown. M032.700 (ABD) and M0330.800 (F&C)

Limited coverage groups who meet the MN requirements, should be evaluated for two prospective and one retro (if applicable) spenddown. This includes QMB, SLMB, QI, QDWI and Plan 1st. A spenddown only case is entitled to one spenddown.

When an applicant meets all the MN eligibility requirements except income they are placed on a spenddown.

Resource limit: $2,000.00 for AU of 1 $3,000.00 for AU of 2

$100 for each additional(M0610.002 F&C) and (M1110.003 ABD)

ABDMedically Needy (MN)

(M0310.002, B)

• Aged - age 65 years or older.• Blind - meets the blind definition• Disabled - meets the disability definition.• Individuals who received Medicaid in December

1973 as AB/APTD related MN and who continue to meet the December 1973 eligibility requirements.

Family & ChildrenMN

(M0330.800)

• Children under age 18• Children under age 1• Pregnant Women• Special Medical Needs Adoption Assistance Children• Individuals under age 21

The policy and procedures for determining whether an individual meets an F&C MN covered group are contained in the following sections:• M0330.801 Pregnant Women;• M0330.802 Newborn Children Under Age 1;• M0330.803 Children Under Age 18;• M0330.804 Individuals Under Age 21;• M0330.805 Special Medical Needs Adoption Assistance.

Can someone on Plan 1st be put on a spenddown?

M01310.001

Individuals enrolled in Plan First do not necessarily meet a MN covered group.

Plan First enrollees who meet a MN covered group and its requirements in M0330 are placed on two six-month spenddown budget periods within the 12 month renewal period.

They may also be eligible for a retroactive MN spenddown determination.

COMPOSING YOUR ARRANGEMENT

(Spenddown Calculation)

$1,380.00 ($1400 gross income-20)

6 (months)

$8280.00

$2,148.04 (group II 7/1/15 limits)

$6,131.96

F&C AND ABD MEDICALLY NEEDY INCOME LIMITS EFFECTIVE 7/1/15

GROUP 1

# of Persons in Family/Budget Unit

Semi-Annual Income

Monthly Income

1 2 3 4 5 6 7 8 9 10 Each add’l person add

1,861.63 2,370.20 2,792.45 3,150.47 3,508.48 3,866.49 4,224.50 4,654.12 5,083.73 5,584.96 481.13

310.27 395.03 465.40 525.07 584.74 644.41 704.08 775.68 847.28 930.82 80.18

GROUP II

Semi-Annual Income

Monthly Income

2,148.04 2,645.09 3,078.88 3,436.89 3,794.89 4,152.90 4,510.92 4,940.53 5,421.74 5,871.37 481.13

358.00 440.84 513.14 572.81 632.48 692.15 751.82 823.42 903.62 978.56 80.18

GROUP III

Semi-Annual Income

Monthly Income

2,792.45 3,366.75 3,794.89 4,152.90 4,510.92 4,868.93 5,226.94 5,584.96 6,103.70 6,515.79 481.13

465.40 561.12 632.48 692.15 751.82 811.48 871.15 930.82 1,017.28 1,085.96 80.18

INCOME LIMITS CHANGE ANNUALLYBE SURE TO CHECK CURRENT BROADCASTS

Income Policy ReferencesCountable income for ABD

• S0820 (earned)• S0820.500 (earned income exclusions)• S0830 (unearned)• M0830.050 (unearned income exclusions)Be sure to always give the $20 general income exclusion

Countable income for F&C• M0720 (earned)• M0720.500 (earned income exclusions)• M0730 (unearned)• M0730.050 (unearned income exclusions)

Three Part Time Signature(Spenddown Budget Periods)

M1330

• Retroactive – 3 months (never longer) immediately preceding the month of application.

• First Prospective – 6 months (never longer).• Consecutive – 6 months immediately

following a prospective spenddown.

The PreludeRetroactive

(M1330.200)

The retroactive spenddown budget period is the 3 months immediately prior to the application month, if none of the months were included in a previous spenddown budget period in which spenddown eligibility was established.

• When one or two of the months in the retroactive period were included in a spenddown budget period in which spenddown eligibility was established, prorate (shorten) the spenddown.

• The retroactive spenddown may also be prorated if the individual dies, or becomes institutionalized.

• Retroactive budget periods are not prorated when an individual is ineligible for another reason; income for all three months is counted.

• When there is a 6-month prospective budget period in which spenddown eligibility is not established, part of that spenddown budget period may become a retroactive spenddown budget period based on a subsequent application.

If an applicant states that a Medicaid covered service was received in any one of the 3 retroactive months, determine eligibility for all months included in the retroactive spenddown budget period.

• Be sure the resources are under the allowable limits each month.• Use actual income minus income exclusions to determine the spenddown

amount.

The ConcertoProspective

(M1330.300)

A prospective budget period is calculated for 6 months. The first prospective budget period begins with the first day of the month of application or the first day of the month after the date Medicaid was canceled because of excess income.

• Prospective budget periods may be prorated (shortened) when the individual becomes ineligible for another reason, dies, or becomes institutionalized.

• Individuals who are eligible for limited Medicaid services must be evaluated for a spenddown. If they meet the MN requirements, they are placed on two 6 month spenddowns. They may also be eligible for a retroactive spenddown (see the previous screen).

• The time standards for Medicaid eligibility determination must be met when determining spenddown.

EncoreConsecutive

(M1330.400)

Consecutive budget periods are any spenddown budget periods that occur when there is no interruption in spenddown eligibility. Consecutive budget periods can occur after there has been a break in spenddown eligibility IF spenddown eligibility has been re-established. A retroactive or prospective spenddown budget period is a consecutive budget period when it follows a spenddown budget period in which eligibility was established.

ApplauseYou have now “performed” one to three spenddowns.

When you send your Notice of Action, send a copy of the “Medical Expense Record - Medicaid” (#032- 03-023) to the applicant for recording his medical expenses. See Appendix 1 to subchapter M1340.

You also must inform the applicant about incurred medical, dental, or remedial care expenses, either paid or unpaid, that can be deducted from the spenddown liability. This can be done by sending the spenddown fact sheet found on SPARK.

The MinuetSpenddown Deductions

(M1340)

Now that the spenddown has been created the next step is to look at the allowable deductions.

Once the allowable deductions reduce the spenddown to ‘0’, full Medicaid coverage will be

granted beginning the day the balance hits zero and ending the last day of the spenddown

period.

ALLOWABLE DEDUCTIONS•

What bills can you use?Only those medical, dental, or remedial care expenses incurred by the applicant, budget unit member(s) and the applicant’s spouse and/or child in the household who is not included in the applicant’s assistance unit. You can also use bills provided by a financially responsible relative on behalf of these individuals.

• If there is no other insurance –Once the bills have been verified, they can be used.

• If there is other insurance or third party liability– An allowable medical expense cannot be deducted until the individual’s insurance or other third party has taken action on the claim and the applicant provides evidence documenting:

• the claim was denied, or • the amount of the claim paid by the third party.

• What if the services were provided by state of local government-Not Medicaid and Medicare (which are federal programs)?

Expenses for incurred medical services received which were provided, covered, or paid for by a state or local government program can be deducted even though the applicant does not owe anything for the service. Expenses covered by Medicare and Medicaid (which are federal programs) CANNOT be deducted.

ALLOWABLE DEDUCTIONS –continued-

• The order you deduct the expenses is important – Expenses are deducted in chronological order based on the date they are incurred. The date incurred is the date the service was received or, in the case of health insurance premiums that are withheld from monthly benefit payments, the first day of the month the premium payment is due. Projected expenses are for services that have not yet been rendered and cannot be deducted until they are incurred.

• What if there are multiple spenddowns , which one do you apply a bill to?

Medical expenses are first deducted from the spenddown period during which they were incurred. If not used to achieve eligibility, the bill can be evaluated for use in succeeding budget periods.

• Can old bills be used and if so, in which spenddown?I’m so glad you asked ………

The Base SectionOld Bills

(M1340.600)

Any unpaid medical, dental and/or remedial care expenses which: • were incurred prior to the Medicaid application’s retroactive

period or • were incurred during the retroactive period if the individual

either did not meet the retroactive spenddown or was not eligible for Medicaid in the retroactive period (for example, due to excess resources), and

• were not fully deducted from (counted in) any previous spenddown budget period where the spenddown was met, and

• they remain the liability of the individual.

Old Bills (continued)

• EXCEPTION: Bills paid by a state or local program are treated as old bills even though they are not the individual’s liability.

An unused portion of an old bill which is still the liability of the individual may be applied to a future consecutive spenddown budget period(s) only if there is no break in spenddown eligibility. If there is a break in spenddown eligibility, only current payments made on old bills based on a prior spenddown application can be deducted in the current budget period.

The Alto SectionCarry Over Expenses

(1340.700)

Carry-over expenses are unpaid medical or remedial care expenses that:• were incurred within a retroactive or prospective budget period in

which spenddown eligibility was established,• remain the liability of the individual, and• were not fully counted in any previous spenddown that was met.

Note: Old bills never become carry-over expenses because old bills, bydefinition, are incurred outside a spenddown budget period in which spenddown eligibility was established. Carry-over expenses are incurred during a spenddown budget period in which spenddown eligibility was established.

The Soprano SectionCurrent Payment

(M1340.800)

Current payments are payments made in the current spenddown budget period on unpaid balances of old bills or carry-over expenses incurred before the current spenddown budget period:• which were not fully used in establishing eligibility in a

previous spenddown budget period, and• when there has been a break in spenddown eligibility.

Upon receipt of the requested documentation, determine if there is any remaining amount of the expense that was not used to meet a previous spenddown. If an amount remains, the amount of the current payment can be deducted.

LINK TO FORM ONLINE

PRACTICE TIME

Changes prior to meeting the Spenddown (M1350)

When changes occur in the individual's or family's situation after applying for Medicaid, but before meeting the spenddown liability, the amount of countable income, the spenddown liability and the spenddown budget period may change.

The spenddown can only be shortened for the Retro period if –

• one or two of the months in the retroactive period were included in a prior Medicaid medically needy spenddown budget period in which eligibility was established or

• the only medically needy individual in the assistance unit dies in the first or second month of the retroactive period.

Changes prior to meeting the Spenddown continued….

The spenddown can only be shortened for the prospective period iF –

• the only medically needy individual in the assistance unit dies,

• the only medically needy individual in the assistance unit becomes ineligible before the end of the spenddown budget period because of excess resources or nonfinancial reasons, or

• the individual’s or assistance unit’s covered group classification changes from medically needy to categorically needy.

Procedures for handling

changes prior to meeting the spenddown

• M1350.200 Increase in Assistance Unit Size• M1350.210 Decrease in Assistance Unit Size Not Due To

Institutionalization• M1350.220 Decrease in Assistance Unit Size Due To

Institutionalization• M1350.300 Income Changes• M1350.400 Income Limit Changes• M1350.500 Resource Changes• M1350.600 Nonfinancial Eligibility Requirement Not Met• M1350.700 Change of Covered Group Classification• M1350.800 Individual Becomes Institutionalized• M1350.900 Changes Due To Death

Changes after a spenddown is met (M1360)

1. Spenddown budget periods do not change when changes occur in an individual's or family's situation after meeting a spenddown liability within a spenddown budget period.

2. When there is a decrease in the Assistance Unit, cancel the Medicaid coverage of the deleted assistance unit member(s). The remaining unit members are eligible until the end of the spenddown budget period.

3. When the assistance unit size increases, Medicaid may be requested for the additional member(s). Recalculate the spenddown liability based on the changes in the income limit and the family's income (if any) for the month(s) that the individual(s) is added to the unit and for subsequent month(s).

Change in AU size – causing liability (spenddown amount) changes

(after spenddown is met)

Re-enroll the family with an earlier coverage begin date if the spenddown liability decreases and is met earlier because of the decrease. Enroll the additional unit member(s) no earlier than the date he became a part of the unit.

When the spenddown liability increases, the spenddown budget period does not change. Cancel the family's coverage if the recalculated spenddown liability has not been met.

If the recalculated spenddown liability has been or is met, enroll the additional assistance unit member(s) no earlier than the date he became part of the unit.

Income Changes(after spenddown is met)

• If the income decreases, recalculate the spenddown liability for the spenddown budget period based on the actual income received. If the recalculated spenddown liability is met earlier in the spenddown budget period, re-enroll the eligible members of the unit with the earlier eligibility begin date.

• If the income increases, recalculate the spenddown liability for the spenddown budget period based on the actual income received. If the new spenddown liability has not been met, cancel eligibility. Notify the recipient of the new spenddown liability and the balance of the spenddown liability which must be met by the last day of the spenddown budget period.

Resource changes(after spenddown is met)

• If resources are still under the limits, there is no change to the case.

• If resources exceed the limit, cancel the unit’s Medicaid eligibility after the advance notice is sent if the effective date of cancellation is prior to the end of the spenddown budget period. Do not change the spenddown liability or the spenddown budget period.

Enrollment(M1340.1300)

Enrollment in Medicaid begins the date the retroactive or prospective spenddown was met - the date within the

budget period that the spenddown liability amount, after deducting incurred expenses, reached zero.

• When the spenddown is met entirely by old bills or carry-over expenses, eligibility begins the first day of the prospective budget period.

• When the spenddown is met by current payments or by expenses incurred during the prospective budget period, eligibility begins the date the spenddown was met.

AC codes

once the spenddown is met

Individual is ABD MN and QMB or SLMB:• 028 for an aged individual also QMB;• 048 for a blind individual also QMB;• 068 for a disabled individual also QMB;• 024 for an aged MN individual also SLMB;• 044 for a blind or disabled MN individual also SLMB.

Individual is ABD MN and not QMB or SLMB:• 018 for an aged individual NOT QMB or SLMB;• 038 for a blind individual NOT QMB or SLMB;• 058 for a disabled individual NOT QMB or SLMB.

F&C MN Individuals• 097 PG Woman• 099 MN Newborn• 088 MN child < 18• 086 MN Non IV-E foster care,

Non IV-E Adoption Assistance• 085 MN Juvenile Justice Dept.

Child• 098 MN in an ICF or ICF-MR

*ICF-MR services are not covered for MN recipients

• 086 MN Special Medical Needs Adoption Assistance

Fine TuningSpenddowns at Renewals

The spenddown budget period is based on the application date. At renewal, the new spenddown budget period begins

the month following the end of the previous spenddown budget period if the renewal is filed in the last month of the

spenddown budget period or the following month. If the renewal is filed two or more months after the end of the last

spenddown budget period, the new spenddown budget periods (retroactive or prospective) are based on the date the renewal form was received in the LDSS. Do not complete an early renewal on a spenddown case because the spenddown period must not be shortened by the completion of an early

renewal.

D.C. al fine(Review)

• All dual eligible customers receive 2 six month spenddowns.

• Retroactive spenddowns are only created when there were Medicaid-covered service in the retroactive budget period.

• Determining spenddown eligibility charts can be found in M1340, Appendix 2.

• Medical Expense Record and Spenddown Calculator can be found in SPARK under MA Training.