mmis spenddown webex training

http://dmasva.dmas.virginia.gov/ 1

Department of Medical Assistance Services

August 2012

http://dmasva.dmas.virginia.gov 1


MMIS Spenddown WebEx Training



Agenda• What is a Spenddown?• SD Budget Periods • SD Liability Calculation• SD Deductions• Evaluating a Bill• Changes• MMIS Enrollment of SD Eligibility Segment

2


http://dmasva.dmas.virginia.gov



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



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



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



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


2011 201210 11 12 1 2 3 4 5 6 7 8 9 10 11 12

Application date January 2012Retroactive SD budget period

First Prospective SD budget period Consecutive SD budget period



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.




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


20121 2 3 4 5 6 7 8 9 10 11 12

Application filed January 2012Prospective 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



Calculating Spenddown LiabilityMonthly 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




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



Spenddown Deductions• Medical expenses incurred by the individual,

family member or a relative who is legally responsible for financial support thato are not subject to payment by a third party,o have not already been used to meet a SD, ando remain a liabilityare 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.




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.




Spenddown Deductions • Deductions are made in chronological order

by kind of service – M1340.900 B1. Health insurance expenses – M1340.300

o premiumso deductibleso coinsurance and copays

2. Non-covered services – M1340.4003. Covered services – M1340.500

• For an incurred service, must have a copy of the provider’s bill and documentation that service was medical necessary.



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.




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.




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.




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.




Spenddown Deductions - Order• First deduct unpaid old bills and/or carry-over

expenses on the 1st 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.




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.



Evaluating A Bill - Example

1/15/12 Hospital Patient’s name $14,000 $2,000 $0

Example BillPatient: Example Patient Hospital Fee: $25,000Bill Date: 6/1/12 Insurance Pmt: $10,000 Date of Service: 1/15/12 Patient Pmt: $1,000

Amount Owed: $14,000Amount owed remaining after retro SD $12,000

1st ProspectiveRetro

Application Date: 6/22/12 Process Date: 7/3/12Retroactive Spenddown Liability: $2000.00Retroactive Budget Period: 3/1/12 – 5/31/12



Evaluating A Bill - Example

1/15/12 Hospital Patient‘s Name $12,000 $4,000 $0

Example BillPatient: Example Patient Hospital Fee: $25,000Bill Date: 6/1/12 Insurance Pmt: $10,000 Date of Service: 1/15/12 Patient Pmt: $1,000

Amount owed remaining after retro SD $12,000Amount owed remaining: $8,000

1st ProspectiveRetro

Application Date: 6/22/12 Process Date: 7/3/12First Prospective Spenddown Liability: $4,000.00Spenddown Budget Period 6/1/12 – 11/30/12



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.




Changes - ReportingThe applicant or recipient is required to report all changes to his worker within 10 days of the date the change is known.

The worker should re-evaluate eligibility within 30 days of receiving verification of medical expenses or changes.

The worker sends written notice to the applicant or recipient advising of the results of the re-evaluation of Medicaid eligibility.



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.




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.



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.



MMIS Enrollment - Example

Input the aid category, application date, begin and end dates on the Eligibility Data screen. Select Enter to validate data.



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.)



Spenddown eligibility has been entered and saved.

MMIS Enrollment – Example (cont.)



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.



Requesting Spenddown Entry

• LDSS workers submit a MMIS Coverage Correction form to the DMAS Eligibility and Enrollment Unit (EEU) at [email protected].

• The MMIS Coverage Correction form (Form Number: DMAS-09) can be found in the Form section of the SPARK page.

mailto:[email protected]



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.



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.



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.



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.



Spenddown Entry – Example (cont.)

Limited Medicaid coverage has been end dated.




DMAS EEU staff will input the closed spenddown eligibility segment.




DMAS EEU staff will then re-enter the limited ongoing coverage, if applicable.



Remember…Please send any questions or

proposed topics for future trainings to [email protected].

Send coverage corrections and enrollment questions to the DMAS Eligibility and

Enrollment Unit at [email protected]

Thank you!



mmis spenddown webex training

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