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Effective: December 1, 2006 |
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24.10.05.05ar1 - Client Option Spenddown (Archive) |
Archived: January 1, 2010 |
Clients eligible for an automated monthly spenddown may choose to prepay their spenddown to DHS. This is called client option spenddown.
Example:
Alisa has an automated monthly spenddown of $300. She finds the Explanation of Medical Benefits (EOMB) confusing, and is frequently unsure of which provider she owes money.
Action:
Alisa may benefit from the client option spenddown. She may prepay her $300 spenddown amount the month before it is due. She would pay her April spenddown amount in March, and so on. This will eliminate the need for Alisa to rely on the EOMB to tell her which provider to pay.
Client Option Spenddown Requirements.
Processing a Client Option Spenddown.
Use the client option spenddown only with automated monthly spenddowns.
Do not use the client option spenddown with any of the following spenddowns and obligations:
l Manual monthly spenddown.
l Six-month spenddown.
l Long-Term Care (LTC) spenddown.
l Special Income Standard for Elderly Waiver (SIS-EW) obligation.
l Minnesota Senior Health Options (MSHO).
l Minnesota Disability Health Options (MnDHO).
Clients meeting the criteria for use and who choose to participate in the client option spenddown must complete the following requirements to begin and maintain use of the client option:
l The client must sign the Agreement to Prepay Medical Assistance (MA) Spenddown (DHS-3081). The form provides directions for sending a payment, and explains the consequences of late payments or returned checks.
l Clients must pay the first month of the client option spenddown before it can begin.
Example:
Beatrice completes and returns the DHS-3081 in May. She sends in her spenddown amount in June.
Action:
The client option spenddown will begin in July. Beatrice remains responsible for May and Junes spenddown amounts as noted on her EOMBs.
l Clients must pay the next month’s entire spenddown amount to DHS by the payment cutoff for the current month. The payment cutoff is the 20th day of the month.
Processing a Client Option Spenddown
Follow these steps when processing the client option for an automated monthly spenddown:
1. Explain the client option spenddown requirements to clients who ask about it or who may benefit from using the option.
2. Give the client a copy of the Agreement to Prepay Medical Assistance (MA) Spenddown (DHS-3081) to read and sign. Retain a copy of the signed agreement in the case file.
3. Begin the client option spenddown the month after the client completes the DHS-3081.
n If the client option information is entered in MMIS on or before the 15th day of the month the signed form is returned, MMIS will send the first monthly bill.
n If the client option information is entered in MMIS after the 15th day of the month the signed form is returned, the county agency must send the Client Option Spenddown Bill (DHS-3180) for the first billing.
n MMIS will continue sending bills after the first month. If the recipient amount changes, MMIS will bill for the new amount.
If DHS receives the client's payment after the 20th of the month, MMIS will apply the late payment to the month following the next spenddown month. The month for which the client option payment was due will use ”potluck” processing.
Note: A late payment does not affect the client's eligibility for MA, nor does it result in a loss of the client option spenddown.
Example:
Ted's automated monthly spenddown amount is $80. He signs the DHS-3081 and returns it in June. He pays his July spenddown amount on June 18.
Action:
July’s spenddown has been met with the client option payment. MMIS will bill for the August spenddown amount.
Ted sends in the spenddown payment for August on July 22.
Action:
The spenddown payment cannot be applied to August. It will be applied to September’s spenddown amount.
Ted is responsible to pay providers that have had rejected claims listed on the EOMB.
If a partial payment is received, DHS will apply the partial payment to the first health care claims billed during the month for which the payment was made.
When the health care claims total more than the client option payment amount, DHS will reject claims equal to the balance of the recipient amount. This is also known as ”potluck” processing.
Note: Potluck processing refers to the process of claims being denied until the recipient amount is reached. Clients use the EOMB sent each month to determine which providers to pay. The client must pay the spenddown recipient amount directly to providers who provided services during the spenddown month.
The client must pay the difference between the partial payment amount and the recipient amount to the providers indicated on the EOMB.
A partial payment does not affect the client's eligibility for MA, nor does it result in a loss of the client option spenddown.
Example:
Eugenie has a $130 automated monthly spenddown amount. She completes and returns the DHS-3081. The DHS-3081 and a client option payment of $80 is received on May 10 and does not make any other payments.
Action:
The partial payment of $80 is applied to the first claims submitted by providers with a June services date. The next $50 of claims submitted is rejected, as this is the rest of her spenddown amount. Eugenie is responsible to pay the providers listed on the EOMB.
If the client overpays the client option spenddown amount, the extra money will forward to the next month. The next bill will show the extra amount as a credit.
Note: This may happen if the spenddown amount decreases after the client has already sent the payment for the next month.
Example:
Mary's spenddown amount is $100. She sends her August client option spenddown payment of $100 on July 14. Her spenddown amount is decreased for August to $80 on July 18th.
Action:
$80 of Mary’s $100 payment is applied to her August spenddown. The remaining $20 of the July payment is applied to her September spenddown. Billing in August will show that she owes $60 for September and that she has a $20 credit.
Clients who do not pay the client option spenddown amount in the month before the spenddown month will revert to ”potluck” processing.
Note: Non-payment does not affect the client's eligibility for MA, nor does it result in a loss of the client option spenddown.
l The client must pay the recipient amount to the providers who provided services during that month, which are listed on the EOMB.
l If the client has not paid for several months, discuss the situation with the client. The client may want to end the client option spenddown.
Close the client option spenddown if a client pays with a personal check which has non-sufficient funds (NSF).
Note: Do not close MA eligibility.
The client must pay the full amount of the NSF check and the following month’s payment with a money order or cashier’s check before the client option can be reinstated.
If the client moves to a new county, the servicing county or the receiving county should close the client option spenddown case for these reasons only:
l The client requests that the new county close the client option case.
l A household member is being removed from the client option case. The receiving county should open a new client option case with the current household members in the new county.
l A new household member is being added to the client option spenddown case. The receiving county should open a new client option case with the current household members in the new county.
The 18-month reconciliation process compares the client option spenddown payment to the amount of claims for a month.
l DHS issues a refund for months in which the client paid more for the client option spenddown than the cost of health care services received.
l The refund is the difference between the spenddown amount paid less the cost of services received.
l The 18-month reconciliation process begins for a client in the 19th month after the month the client option spenddown begins.
l The process continues each month.
An 18-Month Reconciliation Letter is sent to clients who have a refund. The text of the letter is as follows:
You, or the person you represent, have chosen to pay your spenddown to the state. This is called Client Option Spenddown. As part of Client Option Spenddown, the state compares the amount of spenddown you paid to the medical bills paid by Medical Assistance each month. If your medical bills are less than the amount you paid to the state, you will get a refund. Each month, the state will look back 18 months from the current month. This is called 18-Month Reconciliation.
The state has determined that you are eligible for a refund. The state has matched the amount you paid to the amount of your medical bills for:
l Month.
l Recipient Name.
l Client Option Spenddown paid.
l Total Medical Bills paid.
l Refund Amount.
You should receive your refund within three to four weeks.
If you have questions, please call the Recipient Help Desk at 651-296-7675 or out-state at 1-800-657-3739.