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Effective: December 1, 2006 |
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23.45.15ar1 - Combination LTC-Medical Spenddowns (Archive) |
Archived: October 1, 2008 |
A combination LTC/Medical spenddown is a spenddown that includes both a LTC spenddown and a medical spenddown.
Who Uses a Combination Spenddown?
Meeting the Medical Spenddown.
Adjusting the Medical Spenddown.
Combination Spenddown Example.
Who Uses a Combination Spenddown?
Clients who may have a Combination LTC/Medical Spenddown include:
l A client using a LTC income calculation who has a penalty period for the full month.
n The LTC portion of the spenddown is $0 because the client is not eligible for MA to cover the LTC services.
n The medical portion of the spenddown is the LTC spenddown amount calculated using the LTC income calculation.
Note: See LTC/EW and Transfers for more information on what medical expenses to apply to the medical portion of the spenddown.
l A client who has not received a required Long-Term Care Consultation (LTCC) screening.
n The LTC portion of the spenddown is $0 because the client is not eligible for MA to cover the LTC services.
n The medical portion of the spenddown is the LTC spenddown amount calculated using the LTC income calculation.
l A client who did have a LTCC but the screening indicates a non-nursing home level of care and the client lives in a Medicaid facility.
n The LTC portion of the spenddown is $0 because the client is not eligible for MA to cover the LTC services.
n The medical portion of the spenddown is the LTC spenddown amount calculated using the LTC income calculation.
l Clients whose cost of care is less than their LTC spenddown have a Combination LTC/Medical Spenddown.
n The LTC portion of the spenddown is the client’s cost of care. Follow LTC spenddown instructions for the LTC portion of the combination spenddown.
n The medical spenddown portion is the result of the LTC income calculation minus the cost of care.
Clients having a Combination LTC/Medical Spenddown must have income recalculated using appropriate deductions and allocations to determine the combination spenddown amounts.
Clients using a combination LTC/Medical spenddown must have income and cost of care determined monthly.
Note: The cost of care will vary each month due to the number of days in the month.
Clients must meet the medical spenddown amount using medical expenses other than the cost of care used for the LTC spenddown.
Clients meeting the monthly medical spenddown in one month of the certification period should remain open for the remainder of months in the certification period.
Medical expenses include:
l Current health insurance premiums. See LTC Insurance Premium Deduction for more information on what premiums can be deducted.
l Other medical expenses. See LTC Medical Expense Deduction for more information on what medical expenses can be deducted.
For EW clients who meet the medical portion of the spenddown, enter the sum of the LTC spenddown amount and the medical spenddown amount in MMIS.
Adjusting the Medical Spenddown
Ten-day notice is required to adjust the medical spenddown portion of the combination spenddown.
l Clients determined to have a combination LTC/Medical spenddown in the current month or any retroactive months, do not have to pay the medical spenddown portion.
Notify the client that the increase will take place for the next month giving 10-day notice.
l Clients whose combination LTC/Medical spenddown is adjusted in the current month or any retroactive months do not have to pay an increase in the medical spenddown.
Molly resides in and LTCF. The results of the LTC income calculation (her original LTC spenddown) is $3050. Her cost of care in the LTCF is $2000.
Action:
Molly must use a combination LTC/Medical spenddown because her cost of care is less than her LTC spenddown. Recalculate the LTC income calculation to remove any health insurance premiums or other medical expenses as deductions.
The LTC income calculation was recalculated. Her new LTC spenddown amount is $3000 because she had a health insurance premium of $50.
Action:
The LTC portion of the combination spenddown is $2,000 (her cost of care). She must pay that amount to the LTCF.
Her medical spenddown portion is $1000 (the difference between the LTC spenddown and the cost of care).
Molly pays $50 for her health insurance premium, $800 for monthly wheelchair rental and she has an unpaid medical bill from a year ago of $600.
Action:
Molly can meet the medical portion of the combination spenddown with the health insurance premium and the other medical expenses. Continue to keep her eligibility open for the remaining months of the certification period.