*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016.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. ***
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Effective: January 1, 2010 |
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24.25 - Spenddown Adjustments |
Archived: June 1, 2016 (Previous Version) |
A medical spenddown must be adjusted and recorded in MMIS when a change occurs resulting in any of the following:
l Decreased spenddown amount.
l Increased spenddown amount.
Note: Provide timely notice when adjusting an increase in a medical spenddown.
l An earlier satisfaction date.
l A decreased recipient amount on the original satisfaction date.
This section of the manual provides information on when claims are reprocessed and when a provider needs to send in new claims.
Reporting Health Care Expenses After Application.
Reporting Health Care Expenses Monthly or at Renewal.
Client Refunds Due to Adjustments.
Reporting Health Care Expenses After Application
Clients may report and verify incurred health care expenses after their application has been processed. Whether the expenses can be used to adjust the spenddown depends on the date the service was incurred and the date the client reports the expense.
l Adjust medical spenddowns for clients who report additional health care expenses after eligibility approval if both of the following conditions are met:
n The date of service is within any of the three months before the month of application or within the initial certification period.
n The client reported the expenses within three calendar months after the month in which the service was incurred.
l Do not adjust the spenddown amount if the client reports a bill more than three months after the month it was incurred, even if the bill was incurred within the three months before the application month.
Note: The bill may be used to meet a future spenddown if it remains unpaid.
Example:
Betty applies for MA on May 6. She is not requesting retroactive coverage. On May 15, the worker approves MA without a spenddown effective May 1. On May 26, Betty calls to report a medical bill with a February 10 date of service. She requests MA retroactive to February.
Action:
Redetermine eligibility beginning with February. Approve MA effective February 1 if Betty is eligible without a spenddown. If she has a spenddown after the recalculation, apply the February 10 bill to the spenddown.
Example:
Barney applies for MA on June 10. He does not request retroactive coverage. The worker approves MA with a six-month spenddown effective June 5. On July 10, Barney calls to report a medical bill with an April 13 date of service and requests MA retroactive to April.
Action:
Redetermine eligibility beginning with April. Adjust the eligibility date if the April bill results in an earlier spenddown satisfaction date.
Example:
Joelle applies for MA on June 13. She does not request retroactive MA. MA is approved effective June 1. On September 5, Joelle calls to report a medical bill incurred on March 15.
Action:
Do not redetermine eligibility since the bill was incurred more than three calendar months before the month in which Joelle reported it. Use this expense to determine spenddown eligibility in the next certification period if you verify that the bill is unpaid at the next renewal.
Reporting Health Care Expenses Monthly or at Renewal
MAXIS sends the Medical Assistance (MA) for Enrollees who have a Spenddown (DHS-5792C) to clients with the approval notice when a client is approved for MA with a spenddown. The DHS-5792C explains how clients can report and verify their medical expenses, such as copays, that MA does not cover. Clients may report these expenses monthly, with their six-month renewal, or with their annual renewal. It may be more beneficial for a client to report and verify health care expenses monthly if the client has a lot of non-covered expenses.
Adjust the recipient amount of a spenddown for the month in which the expense was incurred when clients report and verify health care expenses that MA does not pay.
Example:
Ellen has a monthly spenddown. Her current certification period is January through June. Each month she incurs $20 in copays. Ellen reports her copays monthly. She sends in April’s receipts for her copays on May 15.
Action:
Record Ellen’s copays in MAXIS with the actual date she incurred the copay. This change will create a new eligibility result. It is not necessary to approve this eligibility if the only change is the recipient amount because MAXIS will not send a new notice.
m Send a SPEC/MEMO to Ellen about the change in recipient amount.
m Enter case notes.
m Update the April recipient amount on the RSPD screen in MMIS.
m Do this each month when Ellen reports and verifies her monthly copays.
Example:
Joni has a monthly spenddown. Her current certification period is January through June. Each month she incurs $40 in copays. Joni reports her copays at her six-month renewal. She sends verification of January through May copays in June with the six-month renewal.
Action:
Record Joni’s copays in MAXIS with the actual dates they are incurred. This change will create a new eligibility result. It is not necessary to approve this eligibility if the only change is the recipient amount because MAXIS will not send a new notice.
m Update the recipient amount for each month in which Joni had a copay during the previous certification period on the RSPD spans in MMIS.
m Process the six-month renewal for the next certification period of July through December.
m Add a worker comment to the renewal approval notice explaining the change in the recipient amounts for the months in the previous certification period.
m Enter case notes.
Example:
Tad reports his copays with his annual renewal. He sends verification of January through November copays in December with the annual renewal.
Action:
Record Tad’s copays in MAXIS with the actual dates he incurred the copays. This change will create a new eligibility result. It is not necessary to approve this eligibility if the only change is the recipient amount because MAXIS will not send a new notice.
m Update the recipient amount for each month in which Tad had a copay in the previous certification period on the RSPD spans in MMIS.
Note: Update the satisfaction date as needed if the client has a six-month spenddown.
m Process the annual renewal for the next certification period.
m Add a worker comment to the renewal approval notice explaining the change in the recipient amounts for the months in the previous certification period.
m Enter case notes.
DHS will automatically reprocess claims the providers submit for spenddown adjustments.
Providers should not re-bill or submit duplicate claims. A provider may need to bill for claims not previously submitted depending on the spenddown type.
l Monthly Spenddowns.
DHS will automatically reprocess claims when there is a decrease in spenddown amount for monthly spenddowns.
n If the client is using a client option spenddown, DHS will apply a credit to the next month.
n If the client has a designated provider, claims processing will apply the adjustment to the designated provider's claims.
l Six-Month Spenddowns.
If the recalculated spenddown results in:
n An earlier satisfaction date , providers should send in additional claims.
Notify the client to contact appropriate providers and ask them to submit claims for services incurred on or after the new satisfaction date through the day before the old satisfaction date that were not previously submitted.
n A decreased recipient amount on the original satisfaction date, DHS claims will reprocess the claims automatically for the satisfaction date, even if the payment amount for the claim was $0.
Client Refunds Due to Adjustments
Clients should allow at least two to four weeks for processing refunds due to a spenddown adjustment for costs they have already paid.
Note: The client will not receive a refund if the client did not pay the spenddown to the providers.
l Claims reprocessing uses the order in which the providers submitted their original claims to determine which providers to pay.
l If the client paid the spenddown to more than one provider in the month, the adjustment may go to any of those providers. It is not possible to anticipate which providers will receive adjustments.