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Effective: December 1, 2006 |
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24.15.40ar1 - Associated Recipients (Archive) |
Archived: January 1, 2010 |
An associated recipient is defined as:
"A Minnesota Health Care Program household member whose health care expenses are used to meet another household member's medical spenddown."
Associated recipients are recorded in MMIS to ensure that a household is required to satisfy a common spenddown amount only once using submitted claims. Without a record of associated recipients, claims would require each household member with a spenddown to meet the spenddown separately.
An associated recipient should not be confused with whose health care expenses can be used to meet another’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:
Thom and Tanya are 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 has submitted for payment.
Action:
The $50 bill is rejected and applied 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 submitted the claim for payment.
Action:
Gavin is eligible for MA without a spenddown. MA will be paying for the cost of the service and cannot be applied 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 is applied to Tanya’s remaining $100 of spenddown as well as Thom’s because he is an associated recipient. The spenddown has been met and $50 of the mammogram bill will be covered by MA.
Example:
Marilyn and her daughter Katrina receive RSDI based on Marilyn's disability. Marilyn's income is under 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. Marilyn’s submitted bills will be covered by MA and will not be applied 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 an automated 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 which has been submitted by the provider.
Action:
The dentist bill is applied to Zachary’s spenddown as well as to Josh’s spenddown, as he is 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 has been met with the clinic bill. Zach will remain responsible for the first $25 of the bill and MA will pay the other $50l. Only $25 of the bill can be applied to Josh’s spenddown, because the remainder of the bill is being paid. Josh needs an additional $200 of health care expenses to meet his spenddown which can only be met using his bills.