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Effective: December 1, 2006 |
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24.25ar1 - Spenddown Adjustments (Archive) |
Archived: January 1, 2010 |
A spenddown must be adjusted and recorded in MMIS when a change is made to a spenddown resulting any of the following:
l Decreased spenddown amount.
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.
Late Reporting of Health Care Expenses.
Client Refunds Due to Adjustments.
Late Reporting of Health Care Expenses
Clients may report and verify incurred health care expenses after application. Whether the expenses can be applied to the spenddown, and eligibility redetermined, is based on the date the service was incurred.
l Redetermine eligibility for clients reporting additional health care expenses after eligibility approval or denial if both of the following conditions are met:
n The date of service is within any of the three retroactive months before the month of application.
n The client reported the expenses within three calendar months after the month the service was incurred.
l Do not redetermine eligibility if the client reports a bill more than three months after the month it was incurred, even if the bill was incurred within 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, consider the February 10 bill toward meeting 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, Benny calls 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 it which Joelle reported it. If you verify that the bill is unpaid at the next renewal, use this expense to determine spenddown eligibility in the next certification period.
DHS will reprocess submitted claims automatically 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 Automated Monthly Spenddowns.
DHS will automatically reprocess claims when there is a decrease in spenddown amount for automated monthly spenddowns.
n If the client is using a client option spenddown, DHS will apply a credit to the next month. The client may request a refund.
n If the automated monthly spenddown client has a designated provider, claims processing will apply the adjustment to the designated provider's claims.
l Manual Monthly and 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 request claims be submitted for services incurred on or after the new satisfaction date through the day before the old satisfaction date and which 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 will go to any of those providers.
l It is not possible to anticipate which providers will receive adjustments.