*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: January 1, 2010 |
|
24.15.40 - Associated Recipients |
Archived: June 1, 2016 (Previous Version) |
An associated recipient is a Minnesota Health Care Program household member whose health care expenses are used to meet another household member's medical spenddown.
Record associated recipients in MMIS to ensure that a household is only required to satisfy a common spenddown once using claims the providers submit. Without a record of associated recipients, claims would require each household member with a spenddown to meet the spenddown separately.
Do not confuse an associated recipient with a person whose health care expenses can be used to meet another person’s medical spenddown. See Health Care Expenses for more information on whose bills may be used.
See Household Composition for more information on determining the MA household.
Associated Recipient Examples.
Household members must have both of the following requirements to be considered an associated recipient:
l A medical spenddown.
Note: Clients with a Long-Term Care (LTC) spenddown or a waiver obligation do not have associated recipients.
l The same medical spenddown type.
They may have different:
l Spenddown amounts.
l Major programs.
l Case numbers.
Example:
Thom and Tanya are each eligible for MA as of October 1. Each has a $150 automated monthly spenddown. Their son Gavin is eligible for MA with no spenddown.
Action:
Enter Thom and Tanya as associated recipients on each other’s spenddown record on MMIS because both have a medical spenddown and the same spenddown type. Gavin is not an associated recipient because he does not have a spenddown.
Thom incurs a $50 doctor bill on October 3, which the provider submits for payment.
Action:
MMIS rejects the $50 bill and applies it to Thom’s spenddown. Since Tanya is an associated recipient on Thom’s spenddown record, the amount of the bill is applied to Tanya’s spenddown as well. They must have at least $100 more of health care expenses to meet their spenddowns.
Gavin has emergency surgery on October 5 and his bill is $16,000. The provider submits the claim for payment.
Action:
Gavin is eligible for MA without a spenddown. MA will pay for the cost of the service so it does not apply to either Thom or Tanya’s spenddown.
Tanya has her yearly mammogram on October 15. The provider submits a claim of $150.
Action:
The $150 bill applies to Tanya’s remaining $100 of spenddown, as well as to Thom’s spenddown because he is an associated recipient. The spenddown is met for both enrollees and $50 of the mammogram bill is covered by MA.
Example:
Marilyn and her daughter Katrina receive RSDI based on Marilyn's disability. Marilyn's income is less than the MA FPG standard and she does not have a spenddown. Katrina receives monthly child support income which creates a $75 spenddown for her.
Action:
There is no associated recipient on this case because Katrina is the only household member with a medical spenddown. MA will pay the bills Marilyn’s providers submit. Marilyn's bills will not apply to Katrina’s spenddown.
Example:
Hazel applies for MA for her two sons, Zachary and Josh. Zachary’s father pays $150 child support each month. Josh’s father pays $350 child support each month. Both boys have a monthly spenddown. Zachary has a $100 recipient amount and Josh has a $300 recipient amount.
Action:
Zachary and Josh are associated recipients on each other’s spenddown record because they both have a medical spenddown and the same spenddown type.
Zachary has a dentist bill for $75 on May 1 that his dentist submits for payment.
Action:
The dentist bill applies to Zachary’s spenddown, as well as to Josh’s spenddown as an associated recipient. Zachary needs an additional $25 of health care expenses to meet his spenddown. Josh needs an additional $225 to meet his spenddown.
Zachary has a clinic appointment on May 10 which costs $75.
Action:
Zachary’s spenddown is met with the clinic bill. Zach will remain responsible for the first $25 of the bill and MA will pay the other $50. Only $25 of the bill can apply to Josh’s spenddown, because MA is paying the remainder of the May 10 bill and any other bills Zach incurs in the month. Josh needs an additional $200 of his own health care expenses to meet his spenddown.