|
Effective: December 1, 2006 |
|
|
24.10.10.05arc1 - Manual Monthly Calculation (Archive) |
Archived: January 1, 2010 |
Manual Monthly Spenddown Calculation.
Manual Monthly Spenddown Calculation
Follow these steps to calculate a manual monthly spenddown:
1. Determine a client’s actual monthly net countable income total based on the appropriate Income Calculation.
l If you do not have verification of actual income and health care expenses for any of the months before the processing month, require the client to complete and sign a Household Report Form (HRF) (DHS-2120).
l If you have verified actual income and bills for any of the months before the processing month, do not require HRF.
2. Determine if the client meets the manual monthly spenddown criteria for use or is required to use a manual monthly spenddown. See Manual Monthly Spenddown to help with this determination.
3. Determine the monthly spenddown amount for past months.
Subtract the applicable monthly Federal Poverty Guideline from the monthly net countable income for that month. The results are the client’s manual monthly spenddown amount.
Note: The FPG standard may vary from month to month. Use the highest income standard that would apply for each household member for each month.
Example:
Steve and Mary are applying for MA for their two children. Penny is three years old and Jackie is seven years old. The household income varies monthly and a spenddown is determined. They cannot meet a six-month spenddown using the spenddown standard.
Action:
Determine if the children meet a manual monthly spenddown.
In February January’s eligibility is determined. The children meet the spenddown for January using incurred health care expenses.
Action:
Approve eligibility for January using a manual monthly spenddown.
The HRF for February eligibility is received in March which verifies that Mary is no longer working. The total net countable income is now below the non-spenddown standard.
Action:
Approve eligibility without a spenddown. The children will continue to have a manual monthly determination throughout the certification period.
4. Determine if the client meets the spenddown amount with applicable health care expenses.
Health care expenses must be applied to a manual monthly spenddown in the following order on the dates provided:
a. H Bills:
Apply health insurance and Medicare premium payments made in the month on the first day of the month.
Exception: Do not allow premiums paid by MA, due to cost-effective status or payment by a Medicare Savings Program (MSP), as a health care expense.
b. M Bills:
The unpaid balances of M bills are applied on the first of the month. They may be applied in two ways:
n Chronologically starting with the earliest date of service, until the full amount is used.
n If a client will be paying one of the M bills first, the application of the bills to the spenddown can be prioritized to give the client the advantage of a greater M Bill balance owed at the next recertification.
Verify that the unused amounts of M bills used to meet previous spenddowns remain unpaid when using the bill to meet a current spenddown.
Document the amount of the portion of an M Bill used to meet the spenddown on a copy of the bill itself and in case notes.
c. P Bills:
Apply P bills on the first day of the month in which they were incurred.
Note: The remedial care expense deduction may be an allowable health care expense if the client is living in a regional treatment center, group residential housing, or assisted living.
d. R Bills:
Apply R bills on the date incurred.
5. Apply health care expenses to the spenddown amount for each month. This determines the satisfaction date and recipient amount (if any) for each month.
Note: Do not carry medical expenses forward to the next manual monthly spenddown calculation unless the county denied eligibility for the entire certification period.
Example:
Steve’s manual monthly spenddown for June is $30. He has an old, unpaid medical bill (M bill) for $30. He meets the spenddown for June with that bill.
Steve’s manual monthly spenddown for July is $20. He has $18 doctor bill incurred on July 18 (R bill). Steve is not eligible for MA for the month of July because he cannot meet his spenddown.
Steve’s manual monthly spenddown for August is $40. He has a doctor bill from August 5 (R bill) of $25. He does not have any other health care expenses.
Action:
The July and August doctor bills were used to meet Steve’s monthly spenddown. He was not eligible. They cannot be used to meet future spenddowns.
l If the spenddown amount is met using H, M, and P bills only:
n The satisfaction date is the first day of the month.
n The recipient spenddown amount is $0.
n Carry the unused M bills over to the next months.
l If spenddown amount is not met using H, M, and P bills continue by adding R bills for the month in order of the dates of service until the spenddown amount is met.
n The satisfaction date is the date the bills equal or exceed the spenddown amount.
n Determine the total amount of health care expenses incurred before the satisfaction date. Truncate the total.
n The recipient amount is the difference between the spenddown amount and the total expenses incurred before the satisfaction date.
l If the spenddown amount is not met with H, M, P, and R bills there is no spenddown eligibility for that month.
Note: Do not close the case, but deny eligibility. The case is technically active for the entire certification period.
6. Update the MMIS system with the spenddown amount, satisfaction date and the recipient amount, if the spenddown is met.
7. Send the client the appropriate notification of the spenddown, including:
l The spenddown amount.
l The satisfaction date.
l Bills the client remains responsible for.
l The recipient amount.
l The eligibility determination.
The client must provide a completed and signed HRF. The HRF must:
l Include verified income received in the month of report.
l Include verified health care expenses incurred in the month of report.
l Be received by the last day of the month after the month of reporting.
Complete the following when processing a renewal, and a manual monthly spenddown will continue:
l Use the information reported and verified on the HRFs returned for the first five months of the certification period.
l Determine if the client is likely to be able to meet a spenddown in one or more months of the next certification period based on the reported and verified information. Base this decision on the best estimate of the client's income and health care expenses for the next six months.
Note: The client must provide a HRF in the first month of the new certification period to determine eligibility for the last month of the previous certification period.
n If the client is likely to meet a spenddown in at least one month of the next certification period leave the case open with a manual monthly spenddown.
n If the client is eligible using a different spenddown type, follow calculations for that type.
n If the client is eligible without a spenddown approve eligibility for the next certification period.