Medicaid Policy
Medicaid Policy
A. How to Meet a Spenddown
There are three ways for an individual to meet a spenddown.
· Cash
· Health Insurance Premiums and/or medical bills
· Combined cash and bills
1. Cash. members may choose to pay their full spenddown with cash (check, money order, credit or debit card).
2. Health Insurance Premiums (431-1): Before using cash or medical expenses, subtract health insurance and/or Medicare premiums (when applicable) from countable income. This will reduce the amount of the spenddown.
· This can include premiums paid during the retroactive period.
· The member can choose to pay the remainder in cash. They may also provide proof of medical bills they owe to meet spenddown.
3. Old Medical Expenses. Review medical expenses posted in eREP from past eligibility periods (even if the member did not meet spenddown in such period). Verify and update before using them. If the member still owes some amount to the provider not previously used to meet a spenddown, the bills may be available to meet a current spenddown. Use any available old expenses before using current ones.
· Do not use expenses that met the criteria of an incurred expense in a month the member was eligible for Medicaid. This is because once eligible Medicaid will pay the remainder of the expense. Do not use the bill in later months.
· Do not use any portion of bills actually used to meet a past spenddown.
· Do not use bills paid in full before the start of the new retroactive period.
4. Incurred medical expenses. If there is still a spenddown after applying health insurance premiums, old medical bills or other medical deductions Medicaid will not pay, the member may use current month expenses (incurred expenses) to meet the remaining spenddown.
· Do not combine incurred expenses with cash to meet the remaining spenddown.
· The remaining spenddown can be met with a combination of medical deductions and incurred bills.
5. Cash and medical bills. After applying any available health insurance premiums, and past medical bills that Medicaid will not cover, the member can meet any remaining spenddown with a cash payment.
6. member responsible for pay bills used to meet spenddown. The member accepts responsibility to pay the medical bills used to meet a spenddown. Medicaid does not pay the portion of the bills applied toward the spenddown.
(See 461-8 for policy on applying medical expenses. For members receiving nursing home or home and community based waiver services, see 463)
B. Spenddown Payments from Medical Providers
1. DWS cannot accept cash payment of a spenddown, premium payment or a cost of care for waiver members from a Medicaid provider’s own funds.
2. Providers cannot loan money to a member to make their payment. DWS will return any payment that appears to be from a Medicaid provider.
3. Providers acting as a representative payee for members must certify to DWS that they are following the requirements and making the payment from the member’s funds. See 511-3.
C. Payments from Non-Medicaid Entities
No restriction applies to non-Medicaid entities (not Medicaid providers.) They may pay a member's spenddown, premium or cost of care contribution. Such entities could be a charitable or religious organization, state agencies, non-household members, trust, etc.
D. Application of Medical Expenses or Cash to Meet the Spenddown
1. After meeting a spenddown with a cash payment or medical bills, do not move the cash payment or medical bills to another month. Be sure you know what month the member wants to meet the spenddown before accepting payment or applying medical bills.
2. Members may request a refund if they do not use Medicaid services. However, the agency cannot withdraw premiums to managed care entities, so the agency will reduce any refund by the premiums paid on the member's behalf.
3. Members may alternate month to month between the use of cash and medical expenses to meet their spenddown.
4. If a member who has been using medical expenses sends a check or money order to DWS equal to the spenddown, and indicates which month to use it for spenddown, the eligibility agency assumes the member is choosing to meet their spenddown with cash.
If the member does not meet spenddown in a month that had medical bills available to use, those bills may be allowable as deductions for a future month. Verify the member still owes the bill to the provider. The amount owed at the beginning of the benefit month can be applied toward the spenddown.