Spenddown - Processing

Created on: 
Jul 11 2016

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

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). For more information, see:

Who is eligible for spenddown medical?

Any client whose excess income makes them ineligible for Categorically Needy medical. For more information, see:

Note: For more information on spenddown medical for a client who is eligible for Long Term Care, see Medically Needy LTC in a Medical Facility - with Spenddown (L99)

How long is the spenddown base period?

ACES automatically defaults to a six-month base period, which may be shortened as needed. A base period cannot be changed once the spenddown has been met and benefits have been authorized.

For more information on spenddown base periods, see Certification Period - What are the certification period defaults?

When do spenddown medical benefits begin?

For information on when spenddown medical benefits begin, see:

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 01/01/16 to 06/30/16. Client has a $2000.00 qualifying Hospital bill for 01/21/16. He has no other medical insurance and is responsible for the entire bill. Medical coverage starts 01/21/16 and client is responsible for the first $1800.00 of the bill.
EXAMPLE: Same scenario as above except the client’s only qualifying medical expense is $1200.00 for hearing aids purchased on 01/22/16 and a $600.00 dental bill dated 01/25/16. Medical coverage starts 01/25/16 and the client is responsible for both medical expenses.

Online Processing

How do I shorten a spenddown Assistance Unit (AU) base period?

If the base period needs to be shortened, take the following steps:

  1. On the Spenddown page, click the Start the Assign/Authorize Process button.
  2. On the Spenddown Assign/Authorize Review page, in the Spenddown Details and Liability section, complete the following fields:
  • Spenddown Base Period field - Enter the [new spenddown base period ending month/year].
  • Click the Next button.
  1. The Spenddown Assign/Authorize page displays with the new shortened base period in the Spenddown Base Period field. Click the Next button.
  2. On the Spenddown Assign/Authorize Confirm page, click the Confirm button to confirm the shortened spenddown base period.

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

There are three ways to find the Spenddown Medical Expenses page:

  1. From the Welcome Back page of aces.online, complete the following fields in the Quick Navigation section:
  • Select a Type of ID field - Select Client from the drop down menu.
  • Enter an ID field - Enter the [client ID].
  • Select a Page field - Select Spenddown Medical Expenses from the drop down menu.
  • Click the Go button and the Spenddown Medical Expenses page displays.
  1. On the client's Summary page, select Spenddown Medical Expenses from the Details dropdown list.
  2. On the Spenddown page in the Clients on this Assistance Unit section, click Expenses next to the client’s name.

How do I enter medical expenses?

Note: For a list of medical expenses that can be applied towards the spenddown, see Apple Health eligibility manual - WAC 182-519-0110 Spenddown of excess income for the medically needy program.

To enter medical expenses, take the following steps:

  1. From the Spenddown Medical Expenses page, click Add link.
  2. On the Add Spenddown Medical Expense pop up window, complete the following fields:
  • Expense Type field - Select the appropriate medical expense type from the drop down menu.
  • Rx Description field - Enter [the name of the prescription].
    • This field displays when MA Covered Prescriptions (RX) is selected from the Expense Type drop down menu. 
  • Current Indicator field - Click the radio button to indicate Yes or No.
    • This field displays when Psychiatric Hospitalization (PH) is selected from the Expense Type drop down menu.
  • Verification field - Select the appropriate verification code from the drop down menu.
  • Date Incurred field - Enter the date [MM/DD/YYYY].
  • Expense Amount field - Enter the [expense amount].
  • TPL Amount field - Enter the [amount of the expense covered by another source].
  • Applied Amount field - This is a display only field and displays the amount applied towards a spenddown.
  • Available Amount field - This is a display only field and displays the available amount after deducting the TPL AmountApplied Amount and Other Reductions fields from the Expense 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 the change was made.
  • Expense Paid field - Click the radio button to indicate Yes or No.
  • Provider Name field - Enter the [name of the provider].
  • Notes field - This is a text field where workers can enter a short note (under 100 characters) about the medical expense.
  1. To add more than one medical expense, click the Add More box, otherwise click the Submit button.
  2. 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 assistance unit 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. Click Update next to the expense on the Spenddown Medical Expenses page.
  2. Update the information as needed.
  • Expense Type and Date Incurred fields - These fields are not available to update due to system tracking purposes once the expense has been assigned to a spenddown base period. If an expense entered has the wrong type or date, the expense should be deleted and then re-entered correctly.
  • Applied amount field - This is a display only field and displays the amount applied towards a spenddown.
  • Other Reductions field - Enter an amount that is less than or equal to the Available Amount field.
    • This field is only available once an expense has been assigned to a spenddown base period.
    • If an amount is entered in the Other Reductions field, the Notes field becomes a mandatory entry field for the user to document why the change was made.
  • Available Amount field - This is a display only field and displays the available amount after deducting the amount in the TPL AmountApplied Amount and Other Reductions fields.
  • If the medical expense has already been assigned to a spenddown Assistance Unit (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 Assistance Unit (AU)?
  1. Click the Submit button.

How do I delete a medical expense?

If a medical expense needs to be deleted, take the following steps:

  1. Click Delete next to the expense to be deleted on the Spenddown Medical Expenses page.
  2. Click Submit in the Delete Spenddown Medical Expense pop up window if you want to delete the medical expense. 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 on the Spenddown page 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:

  • Category 0: Psychiatric Hospitalization Emergency
  • Category 1: Current Period - Medicare Premiums and Medicare/Private health insurance cost sharing
  • Category 2: Retroactive Period - Paid Bills incurred during 3 months prior to Application date
  • Category 3: Prior - Unpaid Bills
  • Category 4: Current Period - Bills not covered by Medicaid
  • 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 retroactive) base period and a current base period, complete the historical (or retroactive) base period first. This ensures the medical expenses are selected and applied in the correct order. Finalize the current base period on the following business day.

To assign medical expenses and authorize a spenddown Assistance Unit (AU), take the following steps:

  1. On the Spenddown page, if the ongoing month is not part of the spenddown base period, select a benefit month within the spenddown base period.
  2. From the Spenddown page, click the Start the Assign/Authorize Process button.
  3. On the Spenddown Assign/Authorize Review page:
  1. On the Spenddown Assign/Authorize page all the spenddown medical expenses entered for all household members are listed in priority order.
  • To select all the available medical expenses, click Auto Assign Medical Expenses. When this is clicked, the system selects all the medical expenses that can be used to meet the spenddown automatically without having to individually select bills.
  • 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 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.
  • Click the Next button.
  1. On the Spenddown Assign/Authorize Confirm page:
  • 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.
  • Click the Confirm button.

How do I view medical expenses assigned to a specific Assistance Unit (AU) and base period?

There are two ways to view which medical expenses are assigned to a specific AU and base period:

  • On the Spenddown Medical Expenses page, the AU ID and Base Period fields display which AU and base period the expense is assigned to.
  • On the Spenddown page, the Medical Expenses section displays the list of expenses assigned to the chosen AU and details about each expense.

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 Summary page for the specific client, select Spenddown Medical Expenses from the Details drop down menu. Or you can click the Expenses link next to the client’s name on the Spenddown page.

How do I view medical expenses history?

When you hover over a medical expense row on the Spenddown Medical Expenses page, the message “Click for expense details” displays.

When the row is clicked, the history of that medical expense displays in the History Details window with the following:

  • When the medical expense was created.
  • When it was assigned to an Assistance Unit (AU).
  • When the user last updated the notes for the expense.
  • When it was unassigned from the AU (if it had been unassigned).

How do I un-assign medical expenses from an Assistance Unit (AU)?

Note: 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. Click the Start the Assign/Authorize Process button at the bottom of the Spenddown page.
  2. On the Spenddown Assign/Authorize Review page:
  1. On the Spenddown Assign/Authorize page:
  • 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.
  • Click the Next button.
  1. On the Spenddown Assign/Authorize Confirm page, click the Confirm button.

How do I release medical expenses from a closed or denied Assistance Unit (AU) that was opened in error?

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 Spenddown page, click Release Medical Expenses.
  2. The Confirmation pop up window displays. Click OK and all the medical expenses are unassigned from the AU and base period.

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

To make a medical expense no longer available for future spenddowns, take the following steps:

  1. From the Spenddown Medical Expenses page, click the Update link next to the expense. The Update Spenddown Medical Expense window opens with all the values of the existing medical expense.
  2. In the Other Reductions field, adjust the amount to zero.
  • The Available Amount is then recalculated. When the Available Amount is zero, the medical expense is unavailable for any future spenddown.
  1. Update the Notes field with a brief explanation and click Submit.

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

For more information about split medical expense bills and which medical expenses are covered, see Apple Health eligibility manual - WAC 182-519-0110 Spenddown of excess income for the medically needy program.

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:

  • The Use field on the Spenddown page displays an S - Split Bill, remaining amount may be available for future spenddown periods.
  • 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 - Bill not used to meet spenddown, not available for future spenddown periods 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 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 displays as an available expense that can be assigned to an Assistance Unit (AU) base period.

How do I create a retroactive spenddown base period?

This feature is not currently available for online processing. For more information on retroactive medical, see the Retroactive Medical chapter.

What happens if a client does not meet their spenddown?

The Assistance Unit (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 are un-assigned from the AU and no longer have a Use indicator. Those expenses are available to assign to another base period. For information on what medical expenses can be applied towards meeting a spenddown base period, see Apple Health eligibility manual - WAC 182-519-0110 Spenddown of excess income for the medically needy program.

Can I initiate a review on a Spenddown Assistance Unit (AU)?

If the Spenddown AU for which the review is due is in Active (A) status, a review may be initiated on the following types of AUs:

  • G99 (MN Alternate Living Facility W/Spenddown),
  • K99 (MN Family LTC W/Spenddown),
  • L99 (LTC MN W/Spenddown) or;
  • S99 (MN SSI Related W/Spenddown) the previous AU can be reopened.

If the AU is in MA Spenddown (M) status, an eligibility review can be initiated when the ongoing month is the month after the current base period end month.

Mainframe Processing

How do I create a retroactive spenddown base period?

For more information on how to create a retroactive spenddown base period, see the Retroactive Medical chapter.

Can I initiate a review on a Spenddown Assistance Unit (AU)?

If the Spenddown AU for which the review is due is in [A] - Active status, a review may be initiated on the following types of AUs:

  • G99 (MN Alternate Living Facility W/Spenddown),
  • K99 (MN Family LTC W/Spenddown),
  • L99 (LTC MN W/Spenddown) or
  • S99 (MN SSI Related W/Spenddown).

If the AU is in [M] - MA Spenddown status, an eligibility review can be initiated when the ongoing month is the month after the current base period end month.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.