spenddown - Processing
DSHS Home Page
 
Search     for:


DSHS Home    Acronyms    Alerts    Screens    WAC Number Index    WCCC

spenddown - Processing


Revised June 20, 2014



What is spenddown?

Who is eligible for spenddown medical?

How long is the spenddown certification period?

How do I set up a spenddown AU and base period?

How do I find the Spenddown Medical Expenses page in aces.online?

How do I enter medical expenses?

How do I enter medical expenses for an ineligible spouse or child?

How do I update a medical expense?

How do I delete a medical expense?

Why are the spenddown medical expenses displayed in different sections or categories?

How do I assign medical expenses and authorize spenddown?

How do I view in aces.online which medical expenses are assigned to a specific AU and base period?

How do I view spenddown medical expenses by client ID?

How do I view medical expenses history?

 

How do I un-assign medical expenses from an AU?

How do I release medical expenses from a closed or denied AU?

 

How do I make a medical expense no longer available for future spenddowns?

 

What does the Assistance Unit >> Spenddown page tell me?

What do I do with a split bill from a prior base period?

How do I set up a retro spenddown base period?

When do spenddown medical benefits begin?

What happens if a client does not meet their spenddown?



What is Spenddown?

·         Spenddown is the process by which a client can receive Medically Needy (MN) coverage when their income exceeds the Medically Needy Income Level (MNIL).

 

·         See WAC 182-519-0100 Eligibility for the medical needy program and WAC 182-519-0050 Monthly income and countable resources standards for medically needy (MN).

 Who is eligible for spenddown medical?

·         Any client whose excess income makes them ineligible for Categorically Needy Medical. Spenddown is the process by which a client can receive Medically Needy (MN) coverage.

 

·         See WAC 182-519-0100 Eligibility for the medical needy program and WAC 182-519-0050 Monthly income and countable resources standards for medically needy (MN).

How long is the spenddown certification period?

·         ACES automatically defaults to a six-month base period, which may be shortened to three-months.

 

·         Retroactive medical is three-months immediately prior to the month of application.

How do I set up a spenddown AU and base period?

·         To finalize an AU, see Finalize Application.

 

·         At the end of the finalize process, Edit 1351 – GO TO ACES.ONLINE TO ADD EXPENSES AND/OR AUTHORIZE SPENDDOWN displays. Users can <F4> past this edit.

 

o    The system automatically generates LTR 020-01 – MN Spenddown.

 

·         If the base period needs to be reduced to a three month spenddown base period, take the following steps:

 

o    See EAZ Manual – Medical Assistance - Spenddown (Worker Responsibilities - Base Periods) for details as to which AUs may have a different base period.

 

1.    On the Assistance Unit>> Spenddown page, click the Start the Assign/Authorize Process button. The Assistance Unit>>Spenddown Assign/Authorize Review page displays.

 

2.    On the Assistance Unit>>Spenddown Assign/Authorize Review page, under the Spenddown Details and Liability Section, the ending month/year of the spenddown base period is displayed.

 

o    Click in the box and highlight the ending month/year.

 

o    Type in the new spenddown base period ending month/year.

 

o    Click the Next button.

 

3.    The Assistance Unit>>Spenddown Assign/Authorize page displays and the Spenddown Base Period now shows the new shortened base period. Click the Next button.

 

4.    The Assistance Unit>>Spenddown Assign/Authorize Confirm page displays. To confirm the shortened spenddown base period, click the Confirm button.


NOTE:

The case is in M (Pending Spenddown) status at the AU level but A (Active) at the client level.


How do I find the Spenddown Medical Expenses page in aces.online?

 

·         There are three ways to navigate to the Spenddown Medical Expenses page. They are as follows:

 

1.    From the Welcome Back page of aces.online, use the Quick Navigation section to do the following:

 

o    In the Select a Type of ID drop down box, click Client ID.

 

o    Enter the [client ID] in the Enter an ID box.

 

o    In the Select a Page drop down box, click Spenddown Medical Expenses.

 

o    Click the Go button and the Client >> Spenddown Medical Expenses page displays.   

 

2.    On the Client >> Summary page, under the Details dropdown box, select the Spenddown Medical Expenses link.

 

3.    On the Assistance Unit >>Spenddown page in the Clients on this Assistance Unit box, click the Expenses link next to the client’s name.

 

How do I enter medical expenses?

 

·         See WAC 182-519-0110 Spenddown of excess income for the medically needy program for the medical expenses that can be applied towards the spenddown.

 

·         To enter medical expenses, take the following steps:

 

1.    In aces.online, from the Spenddown Medical Expenses page, click the Add link and the Client Spenddown Medical Expenses - Add box pops up.

 

2.    On the Client Spenddown Medical Expenses – Add box, complete the following fields:

 

o    Expense Type: Enter one of the following expense types:

 

¨        Health Co- Ins (CO)

 

¨        Hospital (HO)

 

¨        MA Covered (MC)

 

¨        MA Covered Prescriptions (RX)

 

·         If RX is chosen, the Rx Description field displays.

 

¨        MA Uncovered (MU)

 

¨        Medicare Premium (PR)

 

¨        Psychiatric Hospitalization (PH)

 

·         If PH is chosen, the Current Indicator field displays.

 

o    Current Indicator: Click the radio button to indicate Yes or No.

 

o    Verification: Select the appropriate verification code from the drop down menu.

 

o    Date Incurred: The date format is MM/DD/YYYY or users can click on the electronic calendar to select a date.

 

o    Expense Amount: Enter the expense amount.

 

o    TPL Amount: Enter the amount of the expense covered by another source such as other health insurance.

 

o    Applied Amount: This is a display only field and displays the amount applied towards a spenddown.

 

o    Available Amount: This is a display only field and displays the available amount after deducting the TPL Amount, Applied Amount and Other Reductions amount from the Expense Amount.

 

o    Expense Paid: Click the radio button to indicate Yes or No.

 

o    Provider Name: Enter the name of the provider, such as the clinic’s name or the pharmacy’s name.

 

    Rx Description: Enter the name of the prescription medication.

 

o    Notes: This is a text field where a short note (under 100 characters) can be entered about the medical expense.

    If an amount is entered in the Other Reductions field, the Notes field becomes a mandatory entry field for the user to document why they made the change.

 

3.    To add more than one medical expense, click the Add More box.

 

4.    Click the Submit button.

 

5.    After expenses have been added, follow the steps in How do I assign medical expenses and authorize spenddown?

 

How do I enter medical expenses for an ineligible spouse or child?

 

·         The Spenddown Medical Expenses page is a client level page, so each person listed on a spenddown AU has their own Spenddown Medical Expenses page.

 

·         To enter medical expenses for the applicant’s ineligible spouse or child, follow the steps in How do I enter medical expenses?

 

How do I update a medical expense?

 

·         To update an existing medical expense, take the following steps:

 

1.    In aces.online, from the Spenddown Medical Expenses page, click the Update link next to the expense. The Update Spenddown Medical Expense box pops up with all the values of the existing medical expense.

 

2.    Update the information as needed.

 

o    Expense Type and Date Incurred: These fields are not available to update due to system tracking purposes. If an expense entered has the wrong type or date, the expense should be deleted and then re-entered correctly.

 

o    Applied amount: This is a display only field and displays the amount applied towards a spenddown.

 

o    Other Reductions: This is an editable field. An amount can be entered or edited in this field.

 

    The Available Amount can be changed by adjusting the Other Reductions amount.

 

    The amount entered in the Other Reductions field must be less than or equal to the Available Amount.

 

    If an amount is entered in the Other Reductions field, the Notes field becomes a mandatory entry field for the user to document why they made the change.

 

o    Available Amount: This is a display only field and displays the available amount after deducting the TPL Amount, Applied Amount, and Other Reductions amount.

 

o    If the medical expense has already been assigned to a spenddown AU and base period, the only field available to update is the Expense Paid field. If you need to update more information, you can un-assign the bill from the AU, which then opens more fields. See How do I un-assign medical expenses from an AU?   

 

3.    Click the Submit button.

 

How do I delete a medical expense?

 

·         To delete an existing medical expense, take the following steps:

 

1.    In aces.online, from the Spenddown Medical Expenses page, click the Delete link and the Delete Spenddown Medical Expense box pops up. 

 

2.    If you want to delete the medical expense, click Submit. If you do not want to delete the medical expense, click Cancel.

 

Why are the spenddown medical expenses displayed in different sections or categories?

 

·         The spenddown medical expenses are displayed in different section or categories based on the policy prioritization rules. The highest priority medical expenses are listed first and then the next highest priority medical expenses are listed below that.

 

·         The Priority/Categories are as follows:

 

o    Category 0: Psychiatric Hospitalization Emergency

 

o    Category 1: Current Period – Medicare Premiums and Medicare Private Health Insurance Cost Sharing

 

o    Category 2: Retroactive Period – Paid Bills incurred during 3 months prior to Application date

 

o    Category 3: Prior – Unpaid Bills

 

o    Category 4: Current Period – Bills not covered by Medicaid

 

o    Category 5: Current Period – Bills potentially covered by Medicaid


How do I assign medical expenses and authorize spenddown?


NOTE:

When assigning medical expenses to a historical (or retro) base period and a current base period on the same day, complete the historical (or retro) base period first. This ensures the medical expenses are selected and applied in the correct order.


·         To assign medical expenses and authorize a spenddown AU, take the following steps:

 

1.    On the Assistance Unit >> Spenddown page, if the ongoing month is not part of the spenddown base period, select a benefit month within the spenddown base period. The Benefit Month selection is at the top right hand part of the page.

 

2.    From the Assistance Unit >>Spenddown page, at the bottom, click the Start the Assign/Authorize Process button.

 

3.    On the Assistance Unit>>Spenddown Assign/Authorize Review page:

 

o    Shorten or extend the base period if needed, see How do I set up a spenddown AU and base period?

 

o    Review the Spenddown Liability and AU Eligibility calculations

 

o    Click the Next button.

 

4.    On the Assistance Unit>>Spenddown Assign/Authorize page all the spenddown medical expenses entered for all household members are listed in priority order.

 

o    To select all the available medical expenses, click the Auto Assign Medical Expenses button. When this button is clicked, the system selects all the medical expenses that can be used to meet the spenddown automatically without having to individually click bills.

 

o    To select each medical bill individually, click the check box next to the medical expense.

 

¨        If you have multiple expenses in one category, you must select the medical expenses in priority order. For Category 5: Current Period – Bills potentially covered by Medicaid, if the expenses are selected out of order, the system outlines in red the check box next to the expense that should be chosen first.

 

¨        As the expenses are selected, the Available Amount and Applied Amount fields change as the system applies the expenses.

 

¨        When the check box next to the last expense needed to meet spenddown is selected, a green checkmark appears next to the Applied Amount. The Remaining Liability amount in the Spenddown Details and Liability section also displays a green checkmark to indicate the spenddown liability has been met.

 

o    Click the Next button.

 

5.    On the Assistance Unit>>Spenddown Assign/Authorize Confirm page:

 

o    If the spenddown liability has been met, the Eligibility Begin Date field in the AU Status section displays the medical approval date. The date is based on the assigned medical expenses.

 

o    If the spenddown liability has been met, the Assistance Unit>>Spenddown Assign/Authorize Confirm page displays the following question at the bottom of the page: Does the client have a medical appointment or need to pick up a prescription today?

 

¨        The radio button defaults to No. After the AU is confirmed, the client's medical eligibility is sent to the ProviderOne system in overnight batch.

 

¨        If the client has a medical appointment or emergent need the day of the approval, click the radio button next to Yes to send client medical eligibility to ProviderOne in real-time.

 

o    Click the Confirm button.

 

¨        If the Yes radio button was selected, a pop-up message displays for users to confirm the client has a medical appointment or needs to pick up a prescription today. Click OK on the message. The system sends the client's medical eligibility to ProviderOne in real-time.

How do I view in aces.online which medical expenses are assigned to a specific AU and base period?

·         There are two ways to view which medical expenses are assigned to a specific AU:

o    On the Client >> Spenddown Medical Expenses page, the AU ID and Base Period fields display which AU and base period the expense is assigned to.

 

o    On the Assistance Unit >> Spenddown page, the Medical Expenses field displays the list of expenses assigned to the chosen AU and details about each expense.

 

·         To view which medical expenses are assigned to a specific AU during a specific base period, select one of the months within the base period in the Benefit Month field in aces.online on the Assistance Unit >>Spenddown page.

 

How do I view spenddown medical expenses by client ID?

 

·         Each client has their own Spenddown Medical Expenses page that lists all their medical expenses. See How do I find the Spenddown Medical Expenses page in aces.online?

 

·         To view medical expenses listed for each client, take the following steps:

 

1.    From the Client >> Summary page for the specific client, on the Details tab, click on Spenddown Medical Expenses. Or you can click the Expenses link next to the client’s name on the Assistance Unit>>Spenddown page.

How do I view medical expenses history?

 

·         On the Client >>Spenddown Medical Expenses page, when you hover over a medical expense row, it displays “click for expense details”.

 

·         When you click into the row, the history of that medical expense displays in the  History Details window with the following details:

 

o    When the medical expense was created.

 

o    When it was assigned to an AU.

 

o    When the user last updated the notes for the expense.

 

o    When it was unassigned from the AU (if ever).


How do I un-assign medical expenses from an AU?

 

·         Spenddown medical expenses can be un-assigned until the AU becomes active. Once the AU is active and the medical expense has been used to meet the spenddown, the medical expense is permanently assigned to the AU.

 

·         To un-assign medical expenses from an AU, take the following steps:

 

1.    From the Assistance Unit >>Spenddown page, at the bottom, click the Start the Assign/Authorize Process button.

 

2.    On the Assistance Unit>>Spenddown Assign/Authorize Review page:

 

o    Shorten or Extend the base period if needed;

 

o    Review the Spenddown Liability and AU Eligibility calculations

 

o    Click the Next button.

 

3.    On the Assistance Unit>>Spenddown Assign/Authorize page:

 

o     Un-check the box next to the medical expense to be un-assigned to the specific AU and base period.

 

¨        If you have multiple expenses in one category, you must un-check the medical expenses in priority order. If an expense is un-checked out of priority order, the system outlines in red the checkbox next to the expense that should remain assigned.

 

o    Click the Next button.

 

4.    On the Assistance Unit>>Spenddown Assign/Authorize Confirm page, click the Confirm button.

How do I release medical expenses from a closed or denied AU?

 

·         In situations where a spenddown AU was opened in error and the AU is currently in closed or denied status, the medical expenses can be released so they are available to be used for a new base period.


NOTE:

Medical expenses can only be released if all months in the base period are closed or denied or a combination of both.


·         To release medical expenses, take the following steps:

 

1.    On the Assistance Unit >> Spenddown page, click on the Release Medical Expenses button.

 

2.    The Confirmation pop up box displays. Click OK and all the medical expenses will be unassigned from the AU and base period.

 

How do I make a medical expense no longer available for future spenddowns?

 

1.    From the Spenddown Medical Expenses page, click the Update link next to the expense. The Update Spenddown Medical Expense box pops up with all the values of the existing medical expense.

 

2.    In the Other Reductions field, adjust the amount to zero.

 

o    The Available Amount will then be recalculated. When the Available Amount is zero, the medical expense is unavailable for any future spenddown.

3.    Update the Notes field with a brief explanation.

 

What does the Assistance Unit >> Spenddown page tell me?

 

·         The Assistance Unit >> Spenddown page provides four sections of information.

 

·         The Assistance Unit section displays the following fields:

 

o    AU ID

 

o    Program

 

o    Review End Date

 

o    Coverage Group

 

o    Head of Household Name

 

o    Head of Household Client ID

 

o    Primary Language

 

o    Extra Help Needed

 

·         The Spenddown Details and Liability section displays the following fields:

 

o    Spenddown Base Period: Displays the base period date range.

 

o    Spenddown Liability: Displays the total spenddown amount.

 

o    Total Applied: Displays the amount applied to the spenddown liability.

 

o    Remaining Liability: Displays the amount left to meet the spenddown liability.

 

o    PII EMER Liability: Displays the EMER liability amount for the PII program only.

 

o    Total Medical Expenses Applied to EMER: Displays the total amount of medical expenses the client has provided to use towards the PII EMER.

 

o    Remaining EMER Liability: Displays the amount still left of the EMER liability.

 

o    Eligibility Begin Date: After the spenddown liability has been met, the date eligibility begins displays.

 

o    AU Status: Displays the AU status such as MA Spenddown (M).

 

·         The Clients on this Assistance Unit section displays the following fields in column format:

 

o    Client ID: Displays the list of clients included as part of the household for this AU.

 

o    Client Name: Displays each client’s name with an Expenses link for each client’s own Spenddown Medical Expenses page.

 

o    Base Period: Displays a date range and the client’s status in each month.  The client’s status information is pulled directly from the STAT screen.

 

·         The Medical Expenses section displays categories of expenses that are associated to the specific AU and details of that expense in a column format in the following fields:

 

o    Type: Displays the expense type.

 

o    Amount: The medical expense amount.

 

o    Date Incurred: Displays the date the bill was incurred.

 

o    Paid: Displays a Y – Yes or N – No to indicate if the expense has been paid.

 

o    Provider Name / Rx Description: Displays the name of the provider or prescription.

 

o    TPL Amount: Displays the amount entered as the third party liability.

 

o    Available Amount: Displays the amount available to be applied towards the spenddown liability.

 

o    Use: Displays the status of the bill as one of the following:

 

¨        U – Bill used to meet spenddown, not available for future spenddown periods

 

¨        S – Split Bill, remaining amount may be available for future spenddown periods 

 

¨        N – Bill not used to meet spenddown, not available for future spenddown periods

 

o    Applied Amount: Displays the amount applied towards the spenddown liability.

 

o    Client Id: Displays the client id for the person the expense belongs to.

 

o    Client Name: Displays the client’s name.


What do I do with a split bill from a prior base period?

 

·         See WAC 182-519-0110 Spenddown of excess income for the medically needy program to learn about split medical expense bills and which medical expenses are covered.

 

·         When a medical expense is split between meeting the spenddown liability and having a remaining balance, the system indicates the expense is split by displaying the following:

 

o    The Use field on the Assistance Unit >> Spenddown page displays an S.

 

¨        S – Split Bill, remaining amount may be available for future spenddown periods. 

 

o    The Available Amount and Applied Amount fields display the following amounts:

 

¨        On the top line, the amount in the Available Amount field is the total expense, the Use code is S and Applied Amount is the amount used to meet the currently selected base period.

 

¨        On the bottom line, the amount in the Available Amount field displays. If the expense is crossed out and the Use code is N, the expense cannot be used for future base periods. If the expense is not crossed out and there is no Use code next to the expense, then the amount can be used for a future base period.     

 

·         Users will need to determine if the medical expense type is one that can be applied to a new base period. If it can, then users have to find out from the provider what amount the client still owes at the start of the new base period.

 

·         If the total remaining amount of the bill can be used towards the next spenddown, then the remaining amount will display as an available expense that can be assigned to an AU base period.

 

·         If the remaining amount of the bill at the start of the next base period is different than what was system calculated, then users will need to add a new expense in order to apply the correct amount of the expense to the next base period.

    

      How do I set up a retro spenddown base period?

 

1.    On the AMEN screen:

 

o    Select Option W – Retro Medicaid Copy

 

o    Enter the [AU ID] in the AU ID field. Press <TRANSMIT>.

 

¨        If Edit 0962 - DATA MAY NOT BE COPIED FOR ANY MONTH displays, then the retro months already exist for the AU. To set up a retro spenddown base period in this situation, users must screen a new AU for the retro months.

 

2.    The RMCO screen displays with the three months immediately prior to the month of application:

 

o    Enter [Y] – Yes in the Continue field.

 

3.    On the AMEN:

 

o    Enter Option R – Interim/Hist Change in the Selection field.

 

o    Enter the [AU ID] in the AU ID field.

 

o    Enter [Month and Year] in the Benefit Month (MM YY) field. The benefit month and year entered must be for each of the retro spenddown base period months. Press <TRANSMIT>.

 

¨        For any month the client does not want medical or that should not be included in the retroactive base period, deny the month by entering [a 500 level reason code] in the AU STAT field on the STAT screen. See Deny an Assistance Unit/Client.

 

¨        Update case data as needed for each retroactive month, then call DONE and the AMEN screen displays again.

 

4.    On the AMEN:

 

o    Enter Option X – Finalize RETRO Medicaid in the Selection field. 

 

o    Enter the [AU ID] in the AU ID field. Press <TRANSMIT> and the FRME screen displays with the three retro months listed. Press <TRANSMIT>.

 

5.    On the ELIG screen, enter [Y] – Yes in the Confirm field. Press <TRANSMIT>.

 

6.    On the MAFI screen:

 

o    Enter [Y] – Yes in the Bnft Confirm field.

 

o    Enter [Y] or [N] in the Letter Override field. Press <TRANSMIT>.

 

7.    Repeat steps 5 and 6 for each benefit month.

 

8.    Follow the steps in How do I set up a spenddown AU and base period? section above.

 

When do spenddown medical benefits begin?

 

·         For information on when spenddown medical benefits begin see:

 

o    WAC 182-519-0110 Spenddown of excess income for the medically needy program; and

 

o    WAC 182-504-0020 Certification periods for the noninstitutional medically needy (MN) program.

 

·         A base period cannot be changed once spenddown has been met and benefits have been authorized.


EXAMPLE

A client has $300.00 per month is excess income.

Spenddown in this example would be $900.00 for a 3 month base period or $1800.00 for a 6 month base period.

Client’s base period is from 01/01/10 to 06/30/10.

Client has a $2000.00 qualifying Hospital bill for 01/21/10. He has no other medical insurance and is responsible for the entire bill. Medical coverage would start 01/21/10 and client would be responsible for first $1800.00 of the bill and DSHS would be billed for the balance.

Same scenario as above except client’s only qualifying medical expense is $1200.00 for hearing aids purchased on 01/22/10 and a $600.00 dental bill dated 01/25/10. Medical coverage would start 01/25/10 and client would be responsible for these medical expenses.


What happens if a client does not meet their spenddown?

·         The AU is AUTO denied 30 days after the base period has expired with Reason Code 284 – Failed to meet Spenddown Requirement.

 

·         Medical expenses that were assigned to the spenddown base period will be un-assigned from the AU and no longer have a Use indicator. Those expenses will be available to assign to another base period.

·         For information on what medical expenses can be applied towards meeting a spenddown base period, see WAC 182-519-0110 Spenddown of excess income for the medically needy program.

 

Modification Date: June 20, 2014