The Spend-Down program MEdicaid

History of the program The Spend-down program began with the Social Security Act Amendments section 1902(a)(17). Permitted medical expenses to be applied toward Medicaid eligibility. Applicants ineligible for Medicaid have excess income. If a person spends their excess income on medical expenses, then they may be eligible for the program. This is why it is called a spend-down. Their excess income must be “spent down to zero” in order to qualify. Initially, Medicaid was only provided to those who were recipients of the social program Aid to Families with Dependent Children (AFDC) but it was expanded in 1966 to include those who were considered “medically needy.”

Essential Facts Applicants must be categorically eligible. (Child, Adult caretaker of minor child, Aged over 65, Pregnant, or Disabled) No income limit for the program. Uses quarterly income – MNIES to determine the client’s liability. If the client’s medical expenses meet or exceed this amount, client is eligible. Non-MAGI related applicants must meet resource limit. Certain bills allowed. MEM H-1011.5 details which bills can be included. Bills should be inputted chronologically. Certification cannot exceed 3 months. Start date is the day the client spends-down. 110-MNP form must be completed and sent to all providers with charges on the SD date. Medicaid will not pay for services w/o this form. Its purpose is to inform providers and Medicaid of the client’s and Medicaid liability.

Non-Magi Related Spend-down (1/4-21):income and resources Establish ineligibility in full benefit program. Establish categorical eligibility. Applicant must be aged or disabled. (This should have been established prior to full benefit review.) Refer to MEM I-1530 for which income is countable. If a client has PHI or Medicare, we must use the client’s liability for the services after insurance has paid. Applicant must meet resource limits. Individual: $2000. Couple: $3000. Verify all resources. Refer to MEM I-1630 for which resources are countable.

Bills, Bills, Bills: MAGI and Non-MAGI The same policy for what bills are allowed in the SD process is the same for MAGI and Non-MAGI related spend-downs. MEM H-1011.5. Bills incurred on the same day must be inputted as follows, Bills not covered by Medicaid Hospital bills (if a client has bills from multiple hospitals on the same day, input the hospital the client went to first chronologically as the first bill in the budget) All other medical bills

Certification Period MAGI and NON-MAGI All spend-downs have a maximum certification period of 3 months. Start date for certification is the date the client spends-down. Month of application is always included in the cert period, unless the cert is completely retroactive. 1 or 2 month certifications are possible, but only under certain conditions. eligibility for a full Medicaid program, excess resources, death, or not meeting a non-financial or categorical requirement in any month of the quarter.

110MNP: MAGI and NON-MAGI This is a form that records Medicaid and patient liability for charges on the SD date. Providers must use this form to bill Medicaid. Only charges on the SD date are included. Medicaid liability must be indicated. Without this answered, Medicaid will not pay for the service.

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