spenddowns peg larson ge her health care training
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Spenddowns Peg Larson Ge Her Health Care Training. Session Goal. Agenda. Spenddown Types Health Care Expenses Case Examples. Spenddown Basics. Which MHCPs allow a spenddown?. MA MA payment of LTC Services. Spenddown Definition. - PowerPoint PPT PresentationTRANSCRIPT
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Spenddowns
Peg LarsonGe Her
Health Care Training
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Session Goal
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Agenda
• Spenddown Types
• Health Care Expenses
• Case Examples
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Spenddown Basics
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Which MHCPs allow a spenddown?
MA
MA payment of LTC Services
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Spenddown Definition
A cost-sharing approach which allows MA eligibility for people whose net countable income is greater then the applicable FPG standard.
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Spenddown Methods
Medical
(Community)
Institutional
(LTC)
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Medical Method(Community)
• MA not requesting LTC
• EW (not SIS) without
a community spouse
• Disability Waivers
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Institutional Method(LTC)
• Residing in LTCF
• EW with community spouse
SIS-EW = Waiver Obligation
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Medical Spenddown Types
Automated Monthly
Manual Monthly
Six-Month (and shortened)
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Automated Monthly Spenddown
• Income - non-varying
• Medical expenses - recurring
• Eligible for certification period
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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
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Manual Monthly Spenddown
• Income – any• Medical expenses – any• Eligible for certification period• Coverage is intermittent
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Manual Monthly Processing
HRF HRFCoverage Eligible
Coverage Ineligible
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Six- Month Spenddown
Six-Month• Income – all
• Medical Expenses – all
• Eligible with coverage for remainder of certification period
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Six-Month Spenddown Example
$649 $1298 $1298 $1947 $1298 $1298
6 month income $7788
6-month FPG - $6846
6-month spenddown $ 942
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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
Reject
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Shortened Spenddown
• Six-month spenddown is interrupted
• New household member added in middle of certification period. New person has a multi-month spenddown.
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Shortened Spenddown Amount Calculation
Countable net income for # of months
– FPG for # of months
Shortened Spenddown Amount
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Shortened Spenddown Example
$649 $1298 $1298 $1947 $1298 $1298
FS ER
4 month income $5192
4-month FPG - $4564
shortened spdn. amt. $ 628
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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
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Medical Expenses
• Verification
• Types of Expenses
• Applying Expenses
• STAT/BILS
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Verifications
Verify all medical expenses!
• Date service was incurred
• Cost of service
• Amount paid
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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
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HaMPeR
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Bills
• Must be incurred• Client responsible for
• Deducted the month incurred
• Enter separately on STAT/BILS
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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.
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Bill 6-Month Spenddown Action
$200 $200 $200 $200
$800 applied on April 1
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Bills - “Moldy”
Old, unpaid medical expenses incurred prior to the certification period
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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
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Bill Example
$3000 M bill
-$1000 Spenddown deduction
$2000 M bill remaining
-$1500 Paid amount
$ 500 Remaining amount
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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
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Bills - Examples
• Non-reimbursed access services• Dependent or other relative medical
expenses• MA, GAMC and MCRE co-payments• Remedial Care expenses• Alternative Care costs
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Bills – 5 conditions
• Medically necessary
• Prescribed or recommended by physician or dentist
• Directly benefits client
• Available through medical provider
• Not reimbursed
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Bills
• Paid or unpaid
• Incurred during the certification period
• Reimbursable
• Applied on date of service after H, M and P bills
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Certification Periods and Expense Types
3 4 5 6 7 821 9 10 11 12
Certification Period
H, P and R BillsM Bills
3 4 5 6 7 821 9 10 11 12
Certification Period
H, P and R BillsM Bills
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Why do we care if expenses are recurring?
Helps to determine if an auto-monthly spenddown can be used.
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What are anticipated medical expenses?
Expenses that can reasonably be expected to be incurred in the
future.
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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.
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What are actual medical expenses?
Expenses that have already been incurred.
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Why are actual expenses important?
Can be used to meet all types of spenddowns.
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MAXIS and Spenddowns
1. No spenddown2. Spenddown not met3. Six-month spenddown4. Automated monthly spenddown5. Manual monthly spenddown
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Case Examples
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Case Scenario 1A
Spenddown Type?
Insurance Premium?
Prescription Costs?
Vitamins?
H Bill
Auto-Monthly
R Bill
P Bill
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Case Scenario 1BSpenddown Type?
Insurance Premium?
Prescription Costs?
Vitamins?
Unpaid dentist bill?
H Bill
Manual Monthly
R Bill
P Bill
M Bill
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Case Scenario 1C
Spenddown Type?
Insurance Premium?
Prescription Costs?
Paid hospital bill?
Unpaid dentist bill?
H Bill
6- Month
R Bill
R Bill
M Bill
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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
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Case Scenario 2BSpenddown Type?
Insurance Premium?
Prescription Costs?
Paid hospital bill?
Unpaid dentist bill?
H Bill
Manual Monthly
R Bill
N/A
M Bill
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Case Scenario 2C
Spenddown Type?
Unpaid dentist bill?
6- Month
M Bill
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Case Scenario 3A
Spenddown Type?
Prescription costs?
Unpaid ER bill?
6- Month
R Bill
M Bill
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Case Scenario 3B
Spenddown Type?
Prescription costs?
Unpaid hospital bill?
Manual Monthly
R Bill
R Bill
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Case Scenario 3C
Spenddown Type?
Prescription costs?
Paid contact lenses bill?
Auto-Monthly
R Bill
P Bill
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Resources
POLI/TEMP –
HCRW (Health Care Rewrite)
HCPM Chapter 24
MMIS User Manual
Health Quest
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Spenddowns are your friends!