460 Payments to Receive Medicaid

Effective Date: June 1, 2020

No previous policy

(Sections in 415 have been rewritten into 460 sections as of June 1, 2020)

Introduction

Some individuals may qualify for Medicaid by making a payment. The payments an individual might need to make depends on the program for which the individual qualifies. Most individuals will pay the Dept. of Workforce Services directly. Individuals residing in a medical institution, such as a nursing home, make payments directly to the institution.

There are three different types of payments individuals make. The type of payment depends on the program for which a individual qualifies. These payments include:

1. Spenddown for medically needy programs (461)

2. MWI premium for the Medicaid Work Incentive program (462)

3. Cost of care contributions for nursing home and some Home and Community Based Services waiver recipients. (463)

Separate sections define these payments. [Some concepts overlap, so policy will link to the applicable section to avoid repetition.]

A. Definitions

Terms used in the sections on payments include:

1. Spenddown. This is the difference between the person's countable income and the applicable income limit. For family-related medically needy groups, the income limit is called the BMS (basic maintenance standard). For aged, blind and disabled people, the income limit is 100% of the FPL (federal poverty level).

2. Basic Maintenance Standard (BMS) means an income eligibility limit that increases as household size increases.

3. Cost of Care Contribution. This is a payment made by someone receiving long-term care services. An individual living in a medical institution and many individuals receiving home and community based care waiver services must pay part of the cost of their care. It is the difference between the person's income and certain allowable deductions.

4. Countable Income. This is the person's gross income minus allowable exclusions, disregards and deductions. Income includes income of a spouse, or parents of a dependent child, living with the individual even if temporarily absent. Income exclusions, disregards and deductions vary based on whether the individual is disabled or a member of a family with dependent children.

5. Medicaid Health Plan or ACO (Accountable Care Organization). This is a formal arrangement between Medicaid and health provider organizations to provide medical services to Medicaid enrollees. Medicaid pays an amount to the Medicaid Health Plan for each recipient. The ACO Plan assures access to medical providers and pays the providers directly for services. Another name for these is “Capitated Health Plans”. Medicaid also pays premiums to contracted agencies to provide mental health services to recipients.

6. MWI (Medicaid Work Incentive) Premium. A disabled person who is working can receive Medicaid by paying a premium rather than a spenddown. The premium is a percentage of the individual's income after certain allowable deductions.

7. Recipient, applicant and individual. These terms refer to the person who is eligible for medical assistance. When policy refers to a recipient's medical expenses or income, this can include income and expenses of family members such as a spouse, parents and dependent children.