Presentation on theme: "1 Department of Medical Assistance Services August 2012 1 Department of Medical Assistance."— Presentation transcript:
http://dmasva.dmas.virginia.gov/ 1 Department of Medical Assistance Services August 2012 http://dmasva.dmas.virginia.gov 1 Department of Medical Assistance Services MMIS Spenddown WebEx Training
http://dmasva.dmas.virginia.gov/ 2 Department of Medical Assistance Services Agenda What is a Spenddown? SD Budget Periods SD Liability Calculation SD Deductions Evaluating a Bill Changes MMIS Enrollment of SD Eligibility Segment 2 Department of Medical Assistance Services http://dmasva.dmas.virginia.gov
http://dmasva.dmas.virginia.gov/ 3 Department of Medical Assistance Services What is a Spenddown? A spenddown (SD) is a safety net for individuals who have extraordinary medical expenses. Not everyone will meet a SD. SD is for individuals who meet all eligibility requirements except income. Individuals can become eligible for Medicaid when the incurred medical expenses equal or exceed the SD liability. Expenses are incurred at the time services are received. Medicaid Eligibility Manual M1310
http://dmasva.dmas.virginia.gov/ 4 Department of Medical Assistance Services What is a Spenddown? SDs are limited to children, pregnant women, aged, blind or disabled Medically Needy (MN) covered groups. No LIFC, Hospice, BCCPTA or Plan First MN groups. Child < age 18; not 19 unless Foster Care, Adoption Assistance, Juvenile Justice or in an institution. Must meet resource requirements for covered group: –Aged, Blind or Disabled $2000 for one; $3000 for two –Families & Children $2000 for one; $3000 for two; plus $100 for each additional family/budget unit member Medicaid Eligibility Manual M1310.100
http://dmasva.dmas.virginia.gov/ 5 Department of Medical Assistance Services What is a Spenddown? SD is the process of comparing countable income to the income limit, determining the SD liability, and deducting incurred medical expenses from the SD liability to achieve eligibility. Medicaid Eligibility Manual M1310.300 B
http://dmasva.dmas.virginia.gov/ 6 Department of Medical Assistance Services Spenddown Budget Periods The SD budget period is based on the application month. The SD budget periods are: Retroactive: three months prior to application month First Prospective: first six months of application or change Consecutive: six months immediately following prospective Note: budget periods for institutionalized individuals are always one month Medicaid Eligibility Manual M1330.100 20112012 101112123456789101112 Application date January 2012 Retroactive SD budget period First Prospective SD budget periodConsecutive SD budget period
http://dmasva.dmas.virginia.gov/ 7 Department of Medical Assistance Services Spenddown Budget Periods - Prorating All SD budget periods are prorated (shortened), when the individual: Dies, Becomes institutionalized, or Becomes eligible in another full benefit Medicaid covered group. Prospective and consecutive SD budget periods may also be prorated when the individual becomes ineligible for another reason. Retroactive budget periods are not prorated when the individual is ineligible for another reason; income for all three months is counted. Medicaid Eligibility Manual M1330.100
http://dmasva.dmas.virginia.gov/ 8 Department of Medical Assistance Services Spenddown Budget Period - Rules If a spenddown liability in a prospective/consecutive budget period is not met and a new application is filed, part of the prior spenddown budget period becomes a retroactive SD budget period based on the new application date. Medicaid Manual M1330.100 Medicaid Eligibility Manual M1330.100 2012 123456789101112 Application filed January 2012 Prospective SD budget period Jan – June SD not met; April, May June become retro period for July 2012 application First prospective SD budget period for July 2012 application
http://dmasva.dmas.virginia.gov/ 9 Department of Medical Assistance Services Calculating Spenddown Liability Monthly countable income* X (multiplied by) number of months in SD budget period - (MINUS) Medically Needy income limit X number of months in SD budget period_____________ = Spenddown Liability * Subtract earned and unearned disregards as appropriate when determining countable income Medicaid Eligibility Manual M1340.1200
http://dmasva.dmas.virginia.gov/ 10 Department of Medical Assistance Services Calculating SD Liability – 6 mo. example $998 per month SSA -20 unearned income disregard 978 countable monthly income x 6 = $5868 $5868.00 Countable income for SD budget period -2046.14 Group II MN limit for 1 as of 7/1/12 $3821.86 SD liability
http://dmasva.dmas.virginia.gov/ 11 Department of Medical Assistance Services Spenddown Deductions Medical expenses incurred by the individual, family member or a relative who is legally responsible for financial support that o are not subject to payment by a third party, o have not already been used to meet a SD, and o remain a liability are deducted from the individual’s SD liability. An expense is incurred on the date liability for the expense arises. The agency must determine which incurred expenses can be deducted. Medicaid Eligibility Manual M1340.100
http://dmasva.dmas.virginia.gov/ 12 Department of Medical Assistance Services Spenddown Deductions Deduct expenses in chronological order based on the date incurred or the date of service. When an individual has established more than one SD period, first deduct expenses from the SD period in which they were incurred. If eligibility is not achieved, the bill can be evaluated for use in future budget periods. Medicaid Eligibility Manual M1340.100
http://dmasva.dmas.virginia.gov/ 13 Department of Medical Assistance Services Spenddown Deductions Deductions are made in chronological order by kind of service – M1340.900 B 1.Health insurance expenses – M1340.300 o premiums o deductibles o coinsurance and copays 2.Non-covered services – M1340.400 3.Covered services – M1340.500 For an incurred service, must have a copy of the provider’s bill and documentation that service was medical necessary.
http://dmasva.dmas.virginia.gov/ 14 Department of Medical Assistance Services Spenddown Deductions – Old Bills Old bills are unpaid medical expenses incurred prior to the retroactive period based on an initial application. Unpaid expenses incurred prior to a re-application and its retroactive period may also be deducted as old bills if they: –were not incurred during a prior SD budget period in which the eligibility was established (approved), or –were incurred during the retroactive period if the retroactive SD was not met or the individual was not eligible in the retroactive period and they were not fully deducted from any previous SD that was met, and –remain the liability of the individual. Medicaid Eligibility Manual M1340.600
http://dmasva.dmas.virginia.gov/ 15 Department of Medical Assistance Services Spenddown Deductions-Carry-Over Expenses Carry-over expenses are unpaid medical expenses that: –were incurred within a retroactive or prospective budget period in which SD eligibility was established; –remain the liability of the individual; and –were not fully counted in any previous SD that was met. Medicaid Eligibility Manual M1340.700
http://dmasva.dmas.virginia.gov/ 16 Department of Medical Assistance Services Spenddown Deductions – Current Payments 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. not fully used in establishing eligibility in a previous SD budget period, and when there has been a break in spenddown eligibility Determine the amount not used for a prior spenddown and subtract the amount of the current payment, effective the date paid. Medicaid Eligibility Manual M1340.800
http://dmasva.dmas.virginia.gov/ 17 Department of Medical Assistance Services Spenddown Deductions - Summary The agency deducts allowable expenses that are the liability of the individual. Expenses are deducted in chronological order (by date of service), then by the kind of service, then by type of bill. Expenses cannot be deducted prior to the date the service is actually rendered. Medicaid Eligibility Manual M1340.900
http://dmasva.dmas.virginia.gov/ 18 Department of Medical Assistance Services Spenddown Deductions - Order First deduct unpaid old bills and/or carry-over expenses on the 1 st day of the SD budget period. Next, deduct paid or unpaid expenses (health insurance premiums, non-covered services, covered services) incurred in the current SD budget period in chronological order by service date. Last, deduct current payments in chronological order by payment date. Medicaid Eligibility Manual M1340.900
http://dmasva.dmas.virginia.gov/ 19 Department of Medical Assistance Services Spenddown Deductions - Record Medical Expense Record – Medicaid, Form 032-03- 023, is used to keep a running record of medical expenses that may be used to meet a spenddown. A copy of the Medical Expense Record must be placed in the agency record.
http://dmasva.dmas.virginia.gov/ 20 Department of Medical Assistance Services Evaluating A Bill - Example 1/15/12 HospitalPatient’s name$14,000$2,000$0 Example Bill Patient: Example PatientHospital Fee: $25,000 Bill Date: 6/1/12Insurance Pmt: $10,000 Date of Service: 1/15/12Patient Pmt: $1,000 Amount Owed: $14,000 Amount owed remaining after retro SD $12,000 1 st ProspectiveRetro Application Date: 6/22/12 Process Date: 7/3/12 Retroactive Spenddown Liability: $2000.00 Retroactive Budget Period: 3/1/12 – 5/31/12
http://dmasva.dmas.virginia.gov/ 21 Department of Medical Assistance Services Evaluating A Bill - Example 1/15/12 HospitalPatient‘s Name$12,000$4,000 $0 Example Bill Patient: Example PatientHospital Fee: $25,000 Bill Date: 6/1/12Insurance Pmt: $10,000 Date of Service: 1/15/12Patient Pmt: $1,000 Amount owed remaining after retro SD $12,000 Amount owed remaining: $8,000 1 st ProspectiveRetro Application Date: 6/22/12Process Date: 7/3/12 First Prospective Spenddown Liability: $4,000.00 Spenddown Budget Period 6/1/12 – 11/30/12
http://dmasva.dmas.virginia.gov/ 22 Department of Medical Assistance Services Changes - Before & After SD Met If a change occurs in the individual‘s situation after applying for Medicaid, but before meeting the SD liability, the amount of countable income, the SD liability and the SD budget period may change! Reevaluate after any changes that occur either before or after an individual meets SD to determine if the spenddown or eligibility is affected. Medicaid Eligibility Manual M1350.100
http://dmasva.dmas.virginia.gov/ 23 Department of Medical Assistance Services Changes - Reporting
http://dmasva.dmas.virginia.gov/ 24 Department of Medical Assistance Services MMIS Enrollment LDSS workers input SD eligibility segments directly into the MMIS when entering coverage for a new application and no ongoing coverage exists. The end date of coverage must be entered by the LDSS worker for segment to close correctly. Medicaid Eligibility Manual M1340.1300
http://dmasva.dmas.virginia.gov/ 25 Department of Medical Assistance Services Retroactive Enrollment Medicaid enrollment in the retroactive period begins the date the retroactive SD was met. When the SD is not met, retroactive SD eligibility does not exist. Medicaid Eligibility Manual M1340.1300 A.
http://dmasva.dmas.virginia.gov/ 26 Department of Medical Assistance Services Prospective Enrollment In the prospective period, enrollment in Medicaid begins the date the SD was met. When the SD is not met, eligibility does not exist. Medicaid Eligibility Manual M1340.1300 B.
http://dmasva.dmas.virginia.gov/ 27 Department of Medical Assistance Services MMIS Enrollment - Example Input the aid category, application date, begin and end dates on the Eligibility Data screen. Select Enter to validate data.
http://dmasva.dmas.virginia.gov/ 28 Department of Medical Assistance Services At the Member Benefits screen confirm the eligibility information is correct, update the FPL status and select Update to save data. MMIS Enrollment – Example (cont.)
http://dmasva.dmas.virginia.gov/ 29 Department of Medical Assistance Services Spenddown eligibility has been entered and saved. MMIS Enrollment – Example (cont.)
http://dmasva.dmas.virginia.gov/ 30 Department of Medical Assistance Services Medicaid Enrollment The entry of closed SD eligibility segments is performed by the DMAS Eligibility and Enrollment Unit (EEU) when there is ongoing coverage in the MMIS. If limited ongoing coverage exists, EEU staff will reenter the coverage.
http://dmasva.dmas.virginia.gov/ 31 Department of Medical Assistance Services Requesting Spenddown Entry LDSS workers submit a MMIS Coverage Correction form to the DMAS Eligibility and Enrollment Unit (EEU) at email@example.com. firstname.lastname@example.org The MMIS Coverage Correction form (Form Number: DMAS-09) can be found in the Form section of the SPARK page.
http://dmasva.dmas.virginia.gov/ 32 Department of Medical Assistance Services Limited Coverage to Spenddown A member of the EEU staff will notify the LDSS by email when the SD entry has been completed. Local agencies should NOT attempt to enter past SD eligibility using Retro Cancel Reinstate as this function does not allow for the entry of an end date.
http://dmasva.dmas.virginia.gov/ 33 Department of Medical Assistance Services EEU Action for Spenddown Request EEU staff will cancel the limited coverage with cancel reason code 097 the day before the SD was met. The SD period will be entered and the limited coverage will be reinstated where appropriate. A reply email will be sent to the LDSS worker advising the request is complete.
http://dmasva.dmas.virginia.gov/ 34 Department of Medical Assistance Services Re-entry of Future Limited Coverage Remember: If the begin date of ongoing limited coverage is 2 months from the month in which action is being taken, the LDSS worker will need to set a personal reminder to enter the limited coverage segment.
http://dmasva.dmas.virginia.gov/ 35 Department of Medical Assistance Services Spenddown Entry - Example DMAS Eligibility and Enrollment staff will cancel limited Medicaid coverage using Super User Code 097 on the day before the begin date of the spenddown period.
http://dmasva.dmas.virginia.gov/ 36 Department of Medical Assistance Services Spenddown Entry – Example (cont.) Limited Medicaid coverage has been end dated.
http://dmasva.dmas.virginia.gov/ 37 Department of Medical Assistance Services Spenddown Entry – Example (cont.) DMAS EEU staff will input the closed spenddown eligibility segment.
http://dmasva.dmas.virginia.gov/ 38 Department of Medical Assistance Services Spenddown Entry – Example (cont.) DMAS EEU staff will then re-enter the limited ongoing coverage, if applicable.
http://dmasva.dmas.virginia.gov/ 39 Department of Medical Assistance Services Remember… Please send any questions or proposed topics for future trainings to email@example.com. firstname.lastname@example.org Send coverage corrections and enrollment questions to the DMAS Eligibility and Enrollment Unit at email@example.com firstname.lastname@example.org Thank you!