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1 Spenddowns Peg Larson Ge Her Health Care Training
2 Session Goal
3 Agenda Spenddown Types Health Care Expenses Case Examples
4 Spenddown Basics
5 Which MHCPs allow a spenddown? MA MA payment of LTC Services
6 Spenddown Definition A cost-sharing approach which allows MA eligibility for people whose net countable income is greater then the applicable FPG standard.
7 Spenddown Methods Medical (Community) Institutional (LTC)
8 Medical Method (Community) MA not requesting LTC EW (not SIS) without a community spouse Disability Waivers
9 Institutional Method (LTC) Residing in LTCF EW with community spouse SIS-EW = Waiver Obligation
10 Medical Spenddown Types Automated Monthly Manual Monthly Six-Month (and shortened)
11 Automated Monthly Spenddown Income - non-varying Medical expenses - recurring Eligible for certification period
12 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
13 Manual Monthly Spenddown Income – any Medical expenses – any Eligible for certification period Coverage is intermittent
14 Manual Monthly Processing HRF Coverage Eligible Coverage Ineligible
15 Six- Month Spenddown Six-Month Income – all Medical Expenses – all Eligible with coverage for remainder of certification period
16 Six-Month Spenddown Example $649$1298 $1947$ month income $ month FPG- $ month spenddown $ 942
17 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
18 Shortened Spenddown Six-month spenddown is interrupted New household member added in middle of certification period. New person has a multi-month spenddown.
19 Shortened Spenddown Amount Calculation Countable net income for # of months – FPG for # of months Shortened Spenddown Amount
20 Shortened Spenddown Example $649$1298 $1947$1298 FS ER 4 month income $ month FPG- $4564 shortened spdn. amt. $ 628
21 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
22 Medical Expenses Verification Types of Expenses Applying Expenses STAT/BILS
23 Verifications Verify all medical expenses! Date service was incurred Cost of service Amount paid
24 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
26 Bills Must be incurred Client responsible for Deducted the month incurred Enter separately on STAT/BILS
27 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.
28 Bill 6-Month Spenddown Action $200 $800 applied on April 1
29 Bills - “Moldy” Old, unpaid medical expenses incurred prior to the certification period
30 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
31 Bill Example $3000M bill -$1000 Spenddown deduction $2000 M bill remaining -$1500 Paid amount $ 500 Remaining amount
32 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
33 Bills - Examples Non-reimbursed access services Dependent or other relative medical expenses MA, GAMC and MCRE co-payments Remedial Care expenses Alternative Care costs
34 Bills – 5 conditions Medically necessary Prescribed or recommended by physician or dentist Directly benefits client Available through medical provider Not reimbursed
35 Bills Paid or unpaid Incurred during the certification period Reimbursable Applied on date of service after H, M and P bills
36 Certification Periods and Expense Types Certification Period H, P and R BillsM Bills Certification Period H, P and R BillsM Bills
37 Why do we care if expenses are recurring? Helps to determine if an auto- monthly spenddown can be used.
38 What are anticipated medical expenses? Expenses that can reasonably be expected to be incurred in the future.
39 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.
40 What are actual medical expenses? Expenses that have already been incurred.
41 Why are actual expenses important? Can be used to meet all types of spenddowns.
42 MAXIS and Spenddowns 1.No spenddown 2.Spenddown not met 3.Six-month spenddown 4.Automated monthly spenddown 5.Manual monthly spenddown
43 Case Examples
44 Case Scenario 1A Spenddown Type? Insurance Premium? Prescription Costs? Vitamins? H Bill Auto-Monthly R Bill P Bill
45 Case Scenario 1B Spenddown Type? Insurance Premium? Prescription Costs? Vitamins? Unpaid dentist bill? H Bill Manual Monthly R Bill P Bill M Bill
46 Case Scenario 1C Spenddown Type? Insurance Premium? Prescription Costs? Paid hospital bill? Unpaid dentist bill? H Bill 6- Month R Bill M Bill
47 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
48 Case Scenario 2B Spenddown Type? Insurance Premium? Prescription Costs? Paid hospital bill? Unpaid dentist bill? H Bill Manual Monthly R Bill N/A M Bill
49 Case Scenario 2C Spenddown Type? Unpaid dentist bill? 6- Month M Bill
50 Case Scenario 3A Spenddown Type? Prescription costs? Unpaid ER bill? 6- Month R Bill M Bill
51 Case Scenario 3B Spenddown Type? Prescription costs? Unpaid hospital bill? Manual Monthly R Bill
52 Case Scenario 3C Spenddown Type? Prescription costs? Paid contact lenses bill? Auto-Monthly R Bill P Bill
53 Resources POLI/TEMP – HCRW (Health Care Rewrite) HCPM Chapter 24 MMIS User Manual Health Quest
54 Spenddowns are your friends!
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