*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016.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. ***
Effective: January 1, 2010 |
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24.10.05.05 - Client Option Spenddown |
Archived: June 1, 2016 (Previous Version) |
Some clients who have a monthly spenddown may choose to prepay their spenddown to DHS. This is called client option spenddown.
Example:
Alisa has a monthly spenddown of $300. She finds the Explanation of Medical Benefits (EOMB) confusing, and is frequently unsure of which provider she owes money.
Action:
Alisa may benefit from the client option spenddown. She may prepay her $300 spenddown amount the month before it is due. She would pay her April spenddown amount in March, and so on. This will eliminate the need for Alisa to rely on the EOMB to tell her which provider to pay.
Client Option Spenddown Requirements.
Processing a Client Option Spenddown.
Use the client option spenddown only with monthly spenddowns.
Do not use the client option spenddown when the client:
l uses a six-month spenddown.
l uses a Long-Term Care (LTC) spenddown.
l is eligible for Special Income Standard for Elderly Waiver (SIS-EW).
l is enrolled in Minnesota Senior Health Options (MSHO).
Clients meeting the criteria for use and who choose to participate in the client option spenddown must:
l sign the Agreement to Prepay Medical Assistance (MA) Spenddown (DHS-3081). The form provides directions for sending a payment, and explains the consequences of late payments or returned checks.
l pay the first month of the client option spenddown before it can begin.
Example:
Beatrice completes and returns the DHS-3081 in May. She sends in her July spenddown amount in June.
Action:
The client option spenddown will begin in July. Beatrice remains responsible for the May and June spenddown amounts as noted on her EOMBs.
l pay the next month’s entire spenddown amount to DHS by the payment cutoff for the current month to avoid potluck processing. The payment cutoff is the 20th day of the month.
Processing a Client Option Spenddown
Follow these steps when processing the client option spenddown:
1. Explain the client option spenddown requirements to clients who ask about it or who may benefit from using the option.
2. Give the client a copy of the Agreement to Prepay Medical Assistance (MA) Spenddown (DHS-3081) to read and sign. Retain a copy of the signed agreement in the case file and enter a case note.
3. Begin the client option spenddown the month after the client completes the DHS-3081.
n MMIS will send the first monthly bill if the client option information is entered in MMIS on or before the 15th day of the month the signed form is returned.
n The county agency must send the Client Option Spenddown Bill (DHS-3180) for the first billing if the client option information is entered in MMIS after the 15th day of the month in which the client returns the signed form.
n MMIS will continue sending bills after the first month. If the recipient amount changes, MMIS will bill for the new amount.
If DHS receives the client's payment after the 20th of the month, MMIS will apply the late payment to the month following the next spenddown month. The month for which the client option payment was due will use potluck processing.
Note: A late payment does not affect the client's eligibility for MA, nor does it result in a loss of the client option spenddown.
Example:
Ted's monthly spenddown amount is $80. He signs the DHS-3081 and returns it in June. He pays his July spenddown amount on June 18.
Action:
July’s spenddown has been met with the client option payment. MMIS will bill for the August spenddown amount.
Ted sends in the spenddown payment for August on July 22.
Action:
The spenddown payment cannot be applied to August. It will be applied to September’s spenddown amount.
Ted is responsible to pay providers who submitted claims that were rejected for MA payment by MMIS for August as listed on the EOMB.
DHS will apply any partial payment to the first health care claims billed during the month for which the payment was made.
When the health care claims total more than the partial client option spenddown amount, DHS will reject claims equal to the balance of the recipient amount (known as potluck processing).
A partial payment does not affect the client's eligibility for MA, nor does it result in a loss of the client option spenddown.
Example:
Eugenie has a $130 monthly spenddown amount for which she has chosen to pay her recipient amount using the client option. She completed and returned the DHS-3081 in January and has been making her full payment by the 20th of each month. However, on May 10, she only sent in a payment of $80 and does not make any other payments in May for June's spenddown.
Action:
MMIS applies the partial payment of $80 to the first claims submitted by providers with a June date of service. The next $50 of claims submitted is rejected because this is the rest of her spenddown amount. Eugenie is responsible to pay the providers listed on the EOMB.
MMIS posts any overpayment of the client option spenddown amount to the next month. The next bill will show the extra amount as a credit.
Note: This may happen if the spenddown amount decreases after the client has already sent the payment for the next month.
Example:
Mary's spenddown amount is $100. She sends her August client option spenddown payment of $100 on July 14. Her spenddown decreases for August to $80 on July 18.
Action:
MMIS applies $80 of Mary’s $100 payment to her August spenddown and the remaining $20 of the July payment to her September spenddown. Billing in August will show that she owes $60 for September and that she has a $20 credit.
Clients who do not pay the client option spenddown amount in the month before the spenddown month will revert to potluck processing.
Note: Non-payment does not affect the client's eligibility for MA, nor does it result in a loss of the client option spenddown.
l The client pays the recipient amount to the providers listed on the EOMB who provided services during that month and whose claims were rejected.
l Contact clients who have not paid for several months to ask if they want to end the client option spenddown.
Close the client option spenddown if a client pays with a personal check that is returned for non-sufficient funds (NSF).
Note: Do not close MA eligibility.
The client must pay the full amount of the NSF check and the following month’s payment with a money order or cashier’s check before the client option can be reinstated.
If the client moves to a new county, the servicing county or the county receiving the case should close the client option spenddown case for these reasons only:
l The client requests that the new county close the client option case.
l A household member is being removed from the client option case. The receiving county should open a new client option case with the current household members in the new county.
l A new household member is being added to the client option spenddown case. The receiving county should open a new client option case with the current household members in the new county.
An 18-month reconciliation process compares the client option spenddown payment to the amount of claims submitted during the 18-month period.
l DHS issues a refund for months in which the client option spenddown payment was more than the cost of health care services received in the same month.
l The refund is the difference between the spenddown amount and the amount of claims submitted.
l The 18-month reconciliation process begins with the 19th month after the month the client option spenddown begins.
l The reconciliation process continues for each subsequent month.
DHS sends an 18-Month Reconciliation Letter to clients who have a refund. The text of the letter is as follows:
"You, or the person you represent, have chosen to pay your spenddown to the state. This is called Client Option Spenddown. As part of Client Option Spenddown, the state compares the amount of spenddown you paid to the medical bills paid by Medical Assistance each month. If your medical bills are less than the amount you paid to the state, you will get a refund. Each month, the state will look back 18 months from the current month. This is called 18-Month Reconciliation.
The state has determined that you are eligible for a refund. The state has matched the amount you paid to the amount of your medical bills for:
l Month.
l Recipient Name.
l Client Option Spenddown paid.
l Total Medical Bills paid.
l Refund Amount.
You should receive your refund within three to four weeks.
If you have questions, please call the Recipient Help Desk at (651) 431-2670 or (800) 657-3739."