Medicaid Policy
Medicaid Policy
Previous Policy (414 rewritten into 463 as of June 1, 2020)
Introduction
Residents of nursing homes and people receiving services from a home and community based waiver program may need to make a payment to receive Medicaid services. There are two different payments:
1) Cost of care contribution
2) Spenddown
Most nursing home residents will pay a cost-of-care contribution. Recipients on an HCB waiver program may need to pay either a cost-of-care contribution or a spenddown. The type of payment depends on which waiver they receive services from and their income.
A. Cost of Care Contribution
Residents of a nursing facility must pay a cost-of-care contribution, unless they only receive Supplemental Security Income, or their income after allowed deductions, including the personal needs allowance, is zero. (See Table II-A) The cost-of-care contribution helps pay for the services they receive in the institution. It reduces the payment the Medicaid agency makes for their care.
1. The contribution is determined using the member's total income, minus certain allowed deductions. Residents pay the contribution to cost of care directly to the facility. A member's contribution must be less than the private-pay rate for the medical coverage they will get from Medicaid (833). Medical coverage includes the nursing home costs as well as other ancillary medical services.
2. Many people on an HCB waiver program must also pay a Contribution to Cost of Care. It is also determined using the member's total income. The primary difference is that the personal needs allowance is higher than that for nursing home residents. The other allowed deductions vary depending on the waiver.
3. Waiver recipients pay this contribution to DWS in the same way a spenddown is paid. However, it is determined differently than a spenddown, and technically, it is not a spenddown.
B. Spenddowns
Some recipients on HCB waivers must spenddown to the medically needy income limit to receive Medicaid. The spenddown is determined the same way it is for the aged, blind or disabled medically needy program; however, we do not deem income from an ineligible spouse or an ineligible parent. To determine the spenddown amount, the member receives the same income disregards as individuals who are not receiving waiver services. members must pay their spenddown to DWS.
C. Medical Expenses and Long-Term Care Costs
Long-term care recipients who must pay a contribution to cost of care or a spenddown may reduce or meet their payment with health insurance premiums and certain medical expenses of the member. There are some limits on the use of medical expenses allowed. These are defined in sec. 463-3.
The payments a long-term care recipient makes to receive Medicaid services cannot be used to reduce or meet a spenddown or cost-of-care contribution for another family member. Medical expenses of the member's family members cannot be used to meet or reduce the member's contribution or spenddown.