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Effective: December 1, 2006 |
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23.45.05ar1 - Long-Term Care Spenddowns (Archive) |
Archived: October 1, 2008 |
Long-term care (LTC) spenddowns are sometimes referred to as institutional spenddowns.
Cost of Care Less Than LTC Spenddown.
LTC Spenddown and Medicare Payments.
LTCF residents and EW clients with a community spouse have an LTC Spenddown.
Note: EW clients who do not have a community spouse use an MA Method B Community Income Calculation and use a medical spenddown if applicable.
SIS-EW clients have a Waiver Obligation.
LTC spenddowns are allowed to be adjusted retroactively without providing ten-day notice.
Apply changes in income or deductions to the LTC spenddown in the month the change occurs.
Clients with an LTC spenddown are required to use the designated provider option.
l They are responsible to pay the facility or EW provider the spenddown amount.
l The facility will bill the client or the authorized representative for the spenddown amount.
Do not close eligibility for a client who does not pay the LTC spenddown amount. Do not adjust the LTC spenddown for non-payment.
l If the client fails to make payments try to find an authorized representative to help the client.
l If the authorized representative fails to make payments disqualify the current authorized representative and attempt to find a new one.
l Make a referral to Social Services if an authorized representative cannot be found.
LTC spenddown clients whose cost of care is less than the LTC spenddown must use a combination LTC/medical spenddown.
l Recalculate the LTC income calculation using appropriate deductions and allocations.
Note: Do not deduct health insurance premiums or other medical expenses for clients with a combination spenddown.
l Continue to follow LTC spenddown policy for the LTC spenddown portion of the combination spenddown.
If the LTC spenddown amount appears to be more than the LTCF or EW cost of care, contact the facility or the EW case manager to request the monthly cost of care.
Note: The cost of care is based on the level of care a client needs and the number of days in the month.
Clients who receive a lump sum or periodic income payment may fluctuate between an LTC spenddown and a combination LTC/medical spenddown within a certification period.
Attempt to anticipate changes in order to provide ten-day notice of an increase in the medical spenddown portion.
Clients receiving a periodic income payment or a lump sum which causes excess assets for the month following the receipt of the payment, must reduce assets. See the following manual sections for more information:
LTC Spenddown and Medicare Payments
Medicare Part A will pay for a skilled nursing facility if the client is admitted for three or more consecutive days.
l It will continue to pay for up to 100 days in any one benefit period.
l The client will be responsible for the co-insurance payment which begins after 20 consecutive days.
Medicare makes a determination of liability for nursing facility claims at a later date from the determination of the LTC spenddown amount. Therefore it is not possible to determine the amount that Medicare will actually pay to the facility at the time the spenddown is determined.
Once Medicare makes the payment determination the client’s responsibility to the LTCF may be less than the LTC spenddown amount.
When this occurs the following actions may take place:
l The LTCF does not collect the LTC spenddown amount.
The LTCF may choose to wait until the amount the client actually owes is known.
l The LTCF collects the LTC spenddown before Medicare determination.
An LTCF which collects the LTC spenddown amount before the Medicare determination must refund the client’s excess LTC spenddown payment.
Note: Do not count the refund as income in the month received because it was counted in a previous income calculation. Determine if the refund causes the client to have excess assets. See LTC/EW and Assets.
n If the client has an outstanding balance with the LTCF the client may choose to apply the already paid portion to that balance.
n When a deceased client is owed a refund, the refund becomes a part of the client’s estate that may be subject to estate recovery.
The refund is sent to:
m The county if the county has served the LTCF with an affidavit of collection to recover MA payment.
Note: The county may serve the affidavit or follow estate recovery procedures.
m The personal representative if a probate estate is open and a court order confirms the appointment of that representative.
m The estate if there is not an open probate estate or a court ordered representative.
LTCFs must notify the worker using the Refund or Non-Collection of a Long-Term Care (LTC) Spenddown (DHS-4277) of one of the following:
l The amount and months not collected until the Medicare determination is made.
l The amount refunded to the client.
l The amount refunded to the client used to pay an outstanding balance to the LTCF.