Medicaid Policy
Medicaid Policy
A. All Medically Needy Programs (except nursing home and waivers)
1. Deduct health insurance premiums in the month payment is due.
2. Only deduct an unpaid health insurance premium in a month after the due date if it is not all used to meet spenddown in the month due. The portion not applied already to a spenddown must still be unpaid at the start of the following month.
a. If the whole amount due was used to meet a spenddown in the month due, do not carry over any unpaid balance to the following month.
b. Do not allow a deduction for membership or union dues associated with being eligible for the health insurance. For instance, if the person pays union dues to receive the insurance, the union dues are not part of an insurance premium.
3. Payments in retroactive months.
Deduct health insurance premiums due or paid during the retroactive period as follows:
a. If the individual wants Medicaid and owes a spenddown in the retroactive month, deduct the actual premium due or paid in that month.
b. If the individual does not owe a spenddown or will not receive Medicaid in the retroactive month, use the full premium in a later retroactive month or the application month.
c. If the full premium from the retroactive month is not used to meet that month's spenddown, use it in a later retroactive month or the application month. Use it until the full amount has been allowed as an expense. However, do not use any of it in a month after the application month.
d. To use the premium in more than one retroactive month, post only the amount to be used each month as an expense for such month.
e. To use all or a portion of premiums from the retroactive months in the application month, post that amount only in the application month. Do not carry any forward beyond the application month.
f. Some individuals may not meet spenddown every month. Health insurance premiums they pay in the ineligible months can be deducted in a later spenddown month.
· Deduct the premiums paid in the ineligible months from spenddown in the following month, the same way we do for retroactive months at application.
· Do not go back more than the 3 months before the month they want to meet spenddown.
g. Document actions taken.
[NOTE: Accurately enter effective dates so the premium is used only in the intended months.]
4. Buyout Cases.
When the Health Dept. Buyout program is paying a member's health insurance premium, or a portion of it, deduct the full amount of the health insurance payment in the month it is due. Even though the State makes the payment, allow the whole premium as a health insurance expense for the member (225-6).
B. Medicare Premiums
1. Medicare Part B Premiums. Deduct Medicare premiums from income to help meet a spenddown only as explained in the following rules.
a. In months a member will receive Medicaid or a Medicare Cost Sharing program, the state pays the member's Part B premium. Do not deduct the Part B premium from income in a month the member will be eligible for one of these programs.
[NOTE: Enter the Medicare BUY-IN claim number on the appropriate computer screen. This will ensure a reimbursement of the Medicare premium to the member for the Medicaid, QMB, SLMB, or QI eligible months.]
b. At application, deduct Part B premiums a member paid in retroactive months from income to determine the application month spenddown only if the member will not be eligible for medical assistance in those months.
· Do not deduct any portion of those premiums in any month after the application month.
c. If a member will be eligible for one or two retroactive months, but not all three, deduct the premiums paid in the ineligible months in a later retroactive month, or the application month.
Example: Joe applies in June and requests coverage for May. He receives Medicare and has been paying his Part B Premium. He does not qualify for a Medicare Cost-Sharing program in the retroactive months. He wants to meet the spenddown in May and June. Deduct the Part B premiums he paid in March and April in May or June. He may also have medical bills that could be used.
d. Deduct Medicare premiums another family member pays, if the other family member is not going to receive medical assistance.
e. Some individuals may not meet spenddown every month. If the individual is not on a Medicare Cost-Sharing program, their Part B premiums can be deducted in a later spenddown month.
· Deduct the premiums paid in the ineligible months from spenddown in the following month, the same way we do for retroactive months at application.
· Do not go back more than the 3 months before the month they want to meet spenddown.
2. Deduct Medicare Part D Premiums a member Pays
a. Persons eligible for Medicaid or a Medicare Cost-Sharing program qualify for the Part D Low-Income Subsidy. However, some individuals will still pay a premium for their Part D coverage.
b. If the member pays a Part D premium, post it as a health insurance premium expense and deduct it from income.
· If the member paid Part D premiums in a retroactive month, and will not receive any medical assistance in such month, deduct the Part D premiums paid in a later retroactive month or the application month.
· For members who do not meet spenddown every month, deduct Part D premiums paid in ineligible months like other health insurance premiums described above.
· Part D premiums may change after a person becomes eligible for Medicaid. Verify the amount the member is paying and adjust the deduction accordingly.
3. Deduct Part A Medicare Premiums a member Pays
If a member pays a premium to receive Part A Medicare, deduct the amount of the premium paid like any other health insurance premium. [If another state is paying the premium, contact the Program Specialist for help. (223-1-Resource-Medicare)]
4. When Deeming.
a. When deeming income from a family member who does not receive Medicaid, QMB, SLMB, or QI coverage, deduct the Medicare premiums that person pays in the month it is paid. If paid in a retroactive month, deduct the premiums paid in the manner described above.
b. If income is deemed from a person who is receiving Medicaid, QMB, SLMB or QI coverage, do not deduct the Medicare Part B premium paid for any month that person will be eligible under one of these programs.
c. Deduct Part A premiums and Part D premiums the family member pays as described above.
C. How Premiums are deducted from income
For members who are not residing in an institution nor eligible under a waiver, deduct the cost of health insurance covering the member, spouse or parent of a minor member from the spenddown. The premium may be paid by the member, the member's spouse, or the parent of a minor member when the member lives with that individual.
Deduct premiums in the following manner.
1. Family Medically Needy programs
a. Determine if a member pays premiums for an employer sponsored health insurance plan through a payroll deduction. If the member is paid weekly or bi-weekly, determine the weekly or bi-weekly amount the member pays and factor to get a monthly amount. Deduct this amount from income for the application and ongoing months.
b. Deduct the actual premiums due in retroactive months either in that retroactive month, a later retroactive month, or in the application month, to the extent we did not use the full amounts to make a member eligible in the month it was due. Do not allow these amounts after the application month.
c. If the member paid Medicare premiums in the retroactive months, see B. above.
2. Aged, Blind or Disabled Medically Needy
a. Deduct the whole premium amount in the month payment is due; do not pro-rate the premium. For instance, if the full premium is due once a quarter, deduct the premium only in that month; do not allow one-third each month of the quarter.
b. When the member pays a premium for an employer sponsored health insurance plan through a payroll deduction, deduct the actual amount paid each month. (In 3rd and 5th paycheck months, decide if the member pays a premium on those checks and adjust the amount of the deduction accordingly.)
c. If the member paid Medicare premiums in the retroactive months, see B. above.