Spenddowns Peg Larson Ge Her Health Care Training

1. SpenddownsPeg LarsonGe HerHealth Care Training

2. Session Goal

3. Agenda • Spenddown Types • Health Care Expenses • Case Examples

4. Spenddown Basics

5. Which MHCPs allow a spenddown? MAMA 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 $159 Doctor visit from 05/10 Rejected $300 RX from 5/11 $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 HRF Coverage Eligible Coverage Ineligible

15. Six- Month Spenddown • Income – all • Medical Expenses – all • Eligible with coverage for remainder of certification period Six-Month

16. Six-Month Spenddown Example $649 $1298 $1298 $1947 $1298 $1298 6 month income $7788 6-month FPG - $6846 6-month spenddown $ 942

17. Six-Month Spenddown Example 6-month spenddown $ 942 $100 Dentist bill 4/10 $542 Doctor bill 4/29 Reject Reject $800 ER bill 5/2 Reject $300 Pay $500

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 $1298 $1947 $1298 $1298 FS ER 4 month income $5192 4-month FPG - $4564 shortened spdn. amt. $ 628

21. Shortened Spenddown Example Shortened spenddown $ 628 $100 Dentist bill 4/10 $542 Doctor bill 4/29 Reject Reject $528 Pay $14 $800 ER bill 5/2 Pay $800

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

25. HaMPeR

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 $200 $200 $200 $800 applied on April 1

29. Bills - “Moldy” Old, unpaid medical expenses incurred priorto 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 $3000 M 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 M Bills H, P and R Bills 1 2 3 4 5 6 7 8 9 10 11 12 Certification Period M Bills H, P and R Bills 1 2 3 4 5 6 7 8 9 10 11 12 Certification Period

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 • No spenddown • Spenddown not met • Six-month spenddown • Automated monthly spenddown • Manual monthly spenddown

43. Case Examples

44. Case Scenario 1A Auto-Monthly Spenddown Type? Insurance Premium? Prescription Costs? Vitamins? H Bill R Bill P Bill

45. Case Scenario 1B Manual Monthly Spenddown Type? Insurance Premium? Prescription Costs? Vitamins? Unpaid dentist bill? H Bill R Bill P Bill M Bill

46. Case Scenario 1C 6- Month Spenddown Type? Insurance Premium? Prescription Costs? Paid hospital bill? Unpaid dentist bill? H Bill R Bill R Bill M Bill

47. Case Scenario 2A Manual Monthly Spenddown Type? Insurance Premium? Paid Dental Bill (T)? Unpaid Hospital Bill? Unpaid Dental Bill (K)? H Bill P Bill M Bill R Bill

48. Case Scenario 2B Manual Monthly Spenddown Type? Insurance Premium? Prescription Costs? Paid hospital bill? Unpaid dentist bill? H Bill R Bill N/A M Bill

49. Case Scenario 2C Spenddown Type? Unpaid dentist bill? 6- Month M Bill

50. Case Scenario 3A 6- Month Spenddown Type? Prescription costs? Unpaid ER bill? R Bill M Bill