***This version of the Health Care Programs Manual has been replaced and is no longer in effect. Please see the current Health Care Programs Manual for policy in effect as of December 1, 2006.***

The terminology used to describe people with disabilities has changed over time. The Minnesota Department of Human Services ("Department") supports the use of "People First" language. Although outmoded and offensive terms might be found within documents on the Department's website, the Department does not endorse these terms.

MDHS Health Care Programs Manual (Eligibility Policy through 11/30/06)

Chapter 0913 - Premiums and Spenddowns

All chapters are numbered beginning with 09. The first chapter is 0901 (Table of Contents).

Chapter 0913

0913

PREMIUMS AND SPENDDOWNS

PDF(s): Apr 06 | Jan 04 | Oct 03 | Jan 03 | Dec 02

0913.01

COMPUTING THE MINNESOTACARE PREMIUM

PDF(s): Aug 01

0913.01.03

MA-EPD PREMIUMS

PDF(s): Jan 06 | Jan 04 | Mar 03 | Jan 03 |

0913.01.03.03

MA-EPD PREMIUMS: ONGOING

PDF(s): Apr 06 | Jan 06 | Jan 04 |

0913.02

PREMIUM PAYMENT OPTIONS

PDF(s): Apr 06 | Jan 04 | Jul 03

0913.02.03

PREMIUM REFUNDS

PDF(s): Jun 02

0913.03

SPENDDOWNS -- MA/GAMC

PDF(s): Jul 04 | Oct 03 | Oct 02

0913.05

WHICH SPENDDOWN TYPE TO USE

PDF(s): Jul 04 | Oct 03

0913.05.03

USE OF MA MONTHLY SPENDDOWN

PDF(s): Jul 01

0913.05.05

USE OF 6-MONTH AND LTC SPENDDOWNS

PDF(s): May 00

0913.07

6-MONTH SPENDDOWN CALCULATION

PDF(s): May 05 | Oct 03

0913.09

AUTOMATED MONTHLY SPENDDOWN CALCULATION

PDF(s): May 05 Oct 03

0913.09.03

CLIENT OPTION SPENDDOWN

PDF(s): Oct 03

0913.09.05

DESIGNATED PROVIDER OPTION

PDF(s): Oct 03

0913.11

MANUAL MONTHLY SPENDDOWN CALCULATION

PDF(s): May 05 | Oct 03

0913.13

LONG TERM CARE SPENDDOWN CALCULATION

PDF(s): Jun 02

0913.13.03

LTC SPENDDOWN -- EW WITH COMMUNITY SPOUSE

PDF(s): Jan 05 | Feb 01

0913.13.05

WAIVER OBLIGATION -- SIS EW

PDF(s): Jul 06 | Jan 06 |Jul 05 | Jan 05 | Jul 04 | Jan 04 | Jul 03 | Jan 03 | Jul 02

0913.13.07

RELATIONSHIP BETWEEN EW AND AC

PDF(s): Oct 03 | Jun 02

0913.15

COMBINATION LTC/MEDICAL SPENDDOWN

PDF(s): Jul 01

0913.17

BEGIN/END USE OF LTC SPENDDOWN - PART 1

PDF(s): Jul 99

0913.17.01

BEGIN/END USE OF LTC SPENDDOWN - PART 2

PDF(s): Jul 01

0913.17.03

BEGIN/END USE OF LTC SPENDDOWN - PART 3

PDF(s): Jul 04

0913.17.05

BEGIN/END USE OF SIS EW WAIVER OBLIGATION

PDF(s): Jul 99

0913.19

SHORTENED SPENDDOWN

PDF(s): Oct 03

0913.19.03

WHEN TO INTERRUPT 6-MONTH CERT. PERIOD

PDF(s): Oct 03 | Mar 03 | Dec 02 | Oct 02

0913.19.05

WHEN NOT TO INTERRUPT 6-MONTH CERT. PERIOD

PDF(s): Jul 04 | Oct 03 | Dec 02 | Oct 02

0913.21

ALLOWABLE MEDICAL BILLS TO MEET SPENDDOWN

PDF(s): Apr 05 | Oct 03 | Jul 03 | Dec 02 | Oct 02 | Jun 02

0913.21.03

DETERMINE NET MEDICAL EXPENSES

PDF(s): Oct 03 | Jun 02

0913.21.05

MINNESOTACARE EXPENSES TO MEET SPENDDOWN

PDF(s): Oct 03

0913.21.07

MINNESOTACARE INPATIENT HOSPITALIZATION

PDF(s): Oct 03 | Mar 03

0913.21.09

BILLS REPORTED AFTER APPROVAL

PDF(s): Oct 03

0913.23

SPENDDOWN NOTICE REQUIREMENTS

PDF(s): Oct 03

PREMIUMS AND SPENDDOWNS 0913

For information about spenddowns, see §0913.03 (Spenddowns--MA).

MinnesotaCare:

All MinnesotaCare enrollees must pay a premium to establish and maintain coverage. MMIS computes the premium amount based on the household size, income, and number of people covered. The MinnesotaCare program pays the rest of the enrollee's cost of coverage through the Health Care Access Fund.

Premiums are computed and billed on a monthly basis. Most enrollees make monthly payments. However, enrollees may choose to pay premiums in advance for up to one year.

Enrollees may pay premiums by check, money order, automatic withdrawal, payroll deduction, or through the tax refund premium payment plan. Enrollees also have the option of making check or credit card payments via the DHS web site.

See §0913.02 (Premium Payment Options). DHS collects and posts all initial and ongoing payments regardless of the household’s choice of enrollment site. If you receive a premium at the county agency in error, forward it to DHS-MinnesotaCare, attn. Cashier, PO Box 64834, St. Paul, MN 55164-0834. Return initial premium payments received with applications to the applicants. Inform applicants that they will receive a First Premium Notice if their applications are approved.

Once the initial payment is received and a case becomes active, monthly premiums are billed approximately 6 weeks before the first day of the coverage month and are due approximately 2 weeks before the first day of the coverage month. For example, MMIS sends October premium billings on August 15. The October premium is due by the September cutoff date (approximately September 15). If the premium has not been received by the September cutoff date, MMIS sends an overdue notice and a cancellation notice effective the end of the current month.

Except for pregnant women and children under 2, coverage is terminated unless the payment is received by noon on the last business day before the coverage month. For example, if the October premium payment has not been received by September 15, MMIS sends a cancellation notice. Coverage terminates September 30 unless the October payment is received by noon on the last business day of September. Households canceled only for nonpayment may be reinstated back to the date of cancellation if they pay all billed premiums by noon on the 20th day following cancellation. See §0915.11.05 (Fail to Pay Premium/Reinstatement). Households who are not reinstated must serve a 4-month penalty period unless they show good cause for nonpayment. See §0915.11 (Fail to Pay Premium/Voluntary Cancellation).

Treat a dishonored payment as failure to pay the MinnesotaCare premium. This includes checks returned for insufficient funds and returned automatic bank withdrawals. Enrollees must replace dishonored payments by a guaranteed form of payment (cashier’s check, money order or cash). If the household fails to make a guaranteed replacement payment, coverage will terminate and the household must serve a 4-month penalty period unless they show good cause for non-payment. See §0915.11 (Fail to Pay Premium/Voluntary Cancellation).

Require a guaranteed form of payment ONLY for dishonored payments. Do not require a guaranteed form of payment for any other current or future premiums owed. If an enrollee’s premium payment check is returned for non-sufficient funds (NSF) or an automatic bank withdrawal has been returned, MMIS User Services will return the check or other bank documentation with a letter requiring a guaranteed form of payment and will send the enrollment representative a copy of the screen print. The MMIS User Services Help Desk also processes chargebacks of payments made via the DHS web site and notifies the enrollee and the worker. Document the returned payment in case notes.

EXAMPLE:

MinnesotaCare receives Joe's September premium payment on August 15. On August 29, MMIS User Services is notified that Joe's check was returned for NSF. MMIS User Services returns the check to Joe with the MS-0811/J. requesting guaranteed payment. MMIS will terminate Joe's coverage for nonpayment if he fails to replace the NSF check with a guaranteed form of payment and he will be subject to a 4-month penalty period. If Joe does replace the NSF check with a guaranteed form of payment, reinstate coverage.

Take action to change the premium amount:

• At the time of the annual renewal if the household's income or household size has changed. See §0905 (Reviews and Renewals) and §0915.07 (Change in Income). • At any time the household reports a change in income that results in a lower premium amount. See §0915.07 (Change in Income). • When the household size changes. See §0915.03 (Adding a Person to the Household) and §0915.05 (Removing a Person From the Household). • When household member is removed from coverage. • The income guidelines change because of a change in law or the annual update of the federal poverty guidelines.

MMIS will make mass changes resulting from a change in law on the new FPG guidelines automatically. In all other situations, the representative must enter the required information for MMIS to recalculate the premium.

M. S. 256L.06 subd. 3

Minnesota Rule 9506.0040 subp. 6, 7

MA:

See §0913.03 (Spenddowns--MA) for spenddown information.

People enrolled in MA for Employed Persons with Disabilities (MA-EPD) must pay monthly premiums. If they have unearned income, they must also pay an unearned income obligation. See §0913.01.03 (MA-EPD Premiums) and §0913.02 (Premium Payment Options).

Take action to change the premium amount:

• At the time of the 6-month review or annual recertification. • When an enrollee reports decreased income and/or increased household size, resulting in a lower premium. • When the income guidelines change because of a change in law, the annual increase in the FPG standards, or the annual COLA increase. • If an EVS match results in an increase in the MA-EPD premium, apply the increased premium amount for the next available month. See §0916.21.03 (MA Overpayments from IEVS Matches).

GAMC:

GAMC has no spenddown provisions. GHO enrollees have a co-payment of the first $1,000 of inpatient hospital charges for each hospitalization.

Return to Top

COMPUTING THE MINNESOTACARE PREMIUM 0913.01

MinnesotaCare:

MMIS computes the premium amount. There are two types of premiums:

• Fixed premiums. Children with household income equal to or less than 150% FPG pay a fixed monthly premium of $4 per enrolled child.

• Sliding scale premiums. Children with household income over 150% FPG and all adult enrollees pay a sliding scale premium. MMIS computes the sliding scale premium based on the household size, income, and number of people covered. Sliding scale premiums change depending on whether 1, 2, or 3 or more people are covered.

EXAMPLE:

Alan and May apply for MinnesotaCare for their 2 children. Their income is over 150% FPG. The children will have a sliding scale premium based on a household of 4 with 2 people covered. If Alan and May are later added to coverage for themselves, the premium will be based on a household of 4 with 3 or more people covered. If Alan and May have a baby who is added to coverage, the premium will be based on a household of 5 or more with 3 or more covered.

If a family with minor children has income under 150% FPG and both children and adults are covered, the family's premium will be a combination of a fixed premium for the children and sliding scale for the adults.

EXAMPLE:

Jean and Stuart apply for MinnesotaCare for themselves and their 3 children. Their income is under 150% FPG. The children will have a premium of $4 per child, or $12 total. Jean and Stuart's premium will be based on a household of 5 with 2 people covered. The family's total monthly premium will be the sliding scale amount for Jean and Stuart plus $12 for the children. For example, if Jean and Stuart's sliding scale premium is $28, the family's total premium would be $40.

The household's account may be adjusted to show a credit if the health plan capitation has not been paid and 1 of the following conditions exists:

• A household member is approved for MA for a future month for which a premium has already been paid. The adjustment must be requested manually in this case. • The household paid the premium in advance and the premium amount decreased during the time the payment covered. Request a manual adjustment to change the premium for the next month. If no manual adjustment is requested, MMIS will make the adjustment and record the credit in 30 to 60 days. • The household paid the premium in advance and coverage was canceled before the period the payment covered. MMIS will cancel all billings for months after the eligibility end date and will create a credit. • The household paid the premium in advance and MMIS has not yet issued a billing for one or more months covered by the advance payment. The account will show a credit until all of the advance payment has applied to premiums. • The household terminates enrollment in the tax refund premium payment plan. See §0913.02 (Premium Payment Options).

See §0913.02.03 (Premium Refunds) for information on issuing refunds.

M. S. 256.9368

M. S. 256.9356 subd. 1

M. S. 256.9358 subd. 1, 2, 3

MA/GAMC:

No provisions.

Return to Top

MA-EPD PREMIUMS 0913.01.03

MinnesotaCare:

No provisions.

MA:

Apply these instructions only to the Medical Assistance for Employed Persons with Disabilities (MA-EPD) program.

To determine the premium amount for a MA-EPD applicant or enrollee:

1. Total all earned and unearned income of the applicant or enrollee. Exclude income sources listed in §0911.05 (Excluded Income). Exclude the income of the person’s spouse. Count the income of biological or adoptive parents who live with MA-EPD applicants or enrollees who are ages 16 and 17.

Unless both spouses are applying for or enrolled in MA-EPD, determine the household size as you would for any MA applicant or enrollee. See §0908.05 (Determining MA/GAMC Household Size). Use this household size even when the applicant or enrollee is receiving services through one of the waivered services (CAC, CADI, MR-RC and TBI). Count spouses and children in the household size even though income is not deemed.

If both spouses are applying for or enrolled in MA-EPD, consider each as a household of 1, or more if there are children in the home. If there are mutual children, count them in both spouses’ household sizes.

2. Enter all required information on MAXIS. MAXIS will calculate the premium on the EBUD panel. See TE09.13.05 (HCRW: Premiums for MA-EPD). The minimum monthly premium for all enrollees is $35. If MAXIS computes a premium of less than $35 based on the sliding fee scale, the premium amount will default to $35.

EXAMPLE:

Amanda has earned income of $2,500 per month. She is certified disabled by SMRT. She has not received SSI for several years because of her income. She lives with her husband Dave, who is not disabled. Dave has earned income of $1,000 per month. To determine MA-EPD eligibility and premium amount, use only Amanda’s income of $2,500 and a household size of 2. She will have a premium since her earnings of $2,500 exceed 100% FPG for a household of 2.

EXAMPLE:

Ben has earned income of $900 per month and is receiving RSDI of $800 per month based on a disability. He is also receiving services through the TBI waiver. Ben lives with his wife Dena who has earned income of $3500 a month. To determine MA-EPD eligibility and premium amount use only Ben’s income and a household size of 2.

Note: If Ben is not eligible for MA-EPD but is still eligible for the TBI waiver, use a household size of 1 when determining eligibility for regular MA.

EXAMPLE:

Shannon and Matt, a married couple, apply for MA-EPD. Shannon is self-employed as an in-home day care provider with net income of $625 per month. She receives RSDI of $800 per month based on disability. Matt has earned income of $3,000 per month and is certified disabled by SMRT. They have joint assets of $25,000, or $12,500 each, which is within the $20,000 asset limit for each spouse.

MAXIS will determine eligibility and premium amount separately for each spouse, using each spouse’s income and a household size of 1.

If Shannon and Matt have a mutual child in the home, determine eligibility separately for Shannon and Matt using each spouse’s income and a household size of 2.

3. If the enrollee has unearned income, MAXIS will calculate an Unearned Income Obligation (UIO) of one-half of one percent of the unearned income. The UIO will be added to the monthly premium.

EXAMPLE:

Yvonne has a premium of $42 based on her earnings. Her gross unearned income is $800. Her UIO is $4 ($800 x .005 = $4) each month. This amount is added to her premium invoice.

County agencies are responsible for issuing initial premium notices and collecting the following premiums:

• Initial premiums for applicants, including the premium for each retroactive month requested and the application month. If the application is processed after the application month, also bill and collect the premium for all months through the processing month. If the application is processed on or after the 15th day of the month in which coverage is approved, collect the premium for the next month as well.

• Any overdue premiums for previous MA-EPD coverage.

• Initial and overdue premiums for MA-EPD enrollees who have been removed from the Special Recovery Unit (SRU) billing system. This includes former enrollees who are reapplying, enrollees removed from or not entered on the system in error, and enrollees closed and reopened in the same month

EXAMPLE:

Karen applies for MA-EPD on October 10 and does not request retroactive coverage. The worker determines she must pay a premium of $35 to qualify for MA-EPD. She also owes an overdue premium of $35 for coverage she had in July. The worker issues an Initial Premium Notice for the July and October premiums on October 12. Both premiums ($70) must be collected before MA-EPD can be approved for October.

EXAMPLE:

Mai applies for MA-EPD on October 5 and requests 3 months of retroactive coverage. The worker determine that Mai must pay a premium of $35 for each month to qualify for MA-EPD. The worker completes the Initial Premium Notice on October 20. Because the initial notice is created after the 15th, the notice includes premiums for July, August, September, October and November. October and November premiums must be collected before MA-EPD can be approved. The premium for each retroactive month must be collected before coverage is approved for that month.

After determining MA-EPD eligibility and premium amount, take the following steps:

1. Approve MAXIS and MMIS results if the applicant is present and pays the premium immediately. Otherwise, pend the results in MAXIS.

2. Review the MA-EPD Overdue Report to determine if there are overdue premiums. This report prints at the county by the 20th day of each month.

3. Complete the Initial Premium Notice (DHS 3547). Mail or give the original notice to the applicant. Include a return envelope addressed to the Initial Premium Notice (DHS 3547) county agency. Retain a copy in the case file.

4. Enter a MAXIS case note including the monthly premium amount, total amount of Initial Premium Notice, and date notice mailed or given to applicant. Set up a TIKL message for 30 days from the date the notice is mailed or given to the applicant.

Allow 30 days from the date of the Initial Premium Notice to pay the premium. Applicants must pay all current and overdue premiums before MA-EPD can be approved. Take the following actions if the premium is paid on or before the due date:

1. Enter a MAXIS case note with the amount paid and the month(s) covered. Document that E-mail was sent to MADE to initiate billing.

2. Approve eligibility results in MAXIS.

3. Send MAXIS E-mail to MADE with subject of MA-EPD Premium New/Changes. Include:

-Enrollee Name

-Case number

-PMI

-Billing Address

-Representative Payee

-Month/Amounts Paid

-SRU Premium Billing Begin Date

-Premium Amount

-County and worker name, worker E-mail code, and comments if any

4. Approve eligibility results in MMIS.

5. Forward payment and Initial Premium Notice stub to DHS at

DHS - MA-EPD

Attn. Cashier

P. O. Box 64836

St. Paul, MN 55164-0836

Include the following information with each premium:

-Enrollee name

-PMI number

-Amount paid

-Which month(s) the payment applies to

If the required premiums are not receive within 30 days of the initial notice, deny MA-EPD and determine MA eligibility under another basis. Add the following worker comments to the notice:

"You are denied Medical Assistance for Employed Persons with Disabilities (MA-EPD) because we did not receive your premium payment by the due date. You may claim "good cause" for late payment. This must be approved by the Department of Human Services (DHS). To claim "good cause", send a letter with your name, address, case number, and reason for late payment to:

DHS Special Recovery Unit

MA-EPD Good Cause

PO Box 64995

St. Paul, MN 55164-0995"

Or it can be faxed to (651) 431-7431.

Applicants must pay premiums for each retroactive month before coverage can be approved for those months.

Return to Top

MA-EPD PREMIUMS: ONGOING 0913.01.03.03

SRU will issue ongoing premium notices and collect all ongoing MA-EPD premiums. SRU mails premium notices on the 4th day of each month, or the next business day if the 4th falls on a weekend or holiday. Premiums are due on the 15th day of the month prior to the month of coverage. Premium decreases due to changes reported during the 6-month budget period are effective with the next available billing cycle.

Review the MA-EPD Overdue Premiums Report between the 20th and cut-off the following month. Terminate MA-EPD with 10-day notice for enrollees who have failed to pay their premiums without good cause. Take the following steps when closing MA-EPD for non-payment:

1. Redetermine eligibility for MA for the following month.

• If MA eligibility exists, approve MAXIS results and enter eligibility information in MMIS. Add the following worker comments to the approval notice:

"Your Medical Assistance for Employed Persons with Disabilities (MA-EPD) program eligibility will end DD/MM/YY because we did not receive your premium by the due date. You may claim "good cause" for late payment. This must be approved by the Department of Human Services (DHS). To claim good cause, send a letter with your name, address, case number, and reason for late payment to:

DHS Special Recovery Unit

MA-EPD Good Cause

PO Box 64995

St. Paul, MN 55164-0995"

Or it can be faxed to (651) 431-7431.

• If MA eligibility does not exist, close MA-EPD on MAXIS on STAT/PACT using reason code A3 (Refused/Failed Required Info) and end eligibility in MMIS. Add the same worker comments to the closing notice.

2. Notify SRU via MAXIS E-mail that the enrollee’s MA-EPD is being closed and to discontinue billing. Include the enrollee’s name, PMI number and effective date of closure. SRU will not discontinue billing without an E-mail.

• If DHS approves good cause for late payment, DHS will send a copy of the approval letter and/or a MAXIS E-mail. Enrollees who have been granted good cause and set up a payment plan will continue to appear on the MA-EPD Overdue Premiums Report. Do not close these enrollees for late payment unless instructed to do so by DHS.

• In some cases, enrollees may pay premiums after the overdue report is generated. If an enrollee reports the premium was paid, verify the payment with SRU. Do not end coverage. Reopen MA-EPD if it has been closed.

EXAMPLE:

Joshua fails to pay his August MA-EPD premium by the 15th. On the 20th of the month the Overdue Premium Report is printed at the county. The worker reviews the report on the 21st and sends 10-day notice to terminate MA-EPD for non-payment. Joshua pays his premium on the 23rd and calls his worker when he receives the termination notice. The worker verifies the payment with SRU. MA-EPD remains open.

Determine the premium at application, 6-month review and renewal. Do not change the premium at other times unless the client reports a change that would result in a decreased premium. See §0913 (Premiums and Spenddowns). If a reported change results in a decreased premium, E-Mail MADE. Include the same information required for an initial premium, as well as the new premium amount and the effective date of the change. SRU will bill the new amount on the next billing cycle. SRU will not decrease the premium retroactively except in the case of worker error.

Exception:

If an IEVS match results in an increase in the MA-EPD premium, apply the increased premium amount for the next available month. See §0916.21.03 (MA Overpayments from IEVS Matches).

To maintain a consistent premium for current and future months, when calculating income for MA-EPD:

• Use actual income received in any retroactive months

• Anticipate income for current and future months by multiplying biweekly income by 2.16 and weekly income by 4.3. • When people perform work every month but are paid less often than monthly, average the earnings over the 6-month budget period.

EXAMPLE:

John works part time at a convenience store and is paid weekly. He is also a member of his town’s council, for which he receives payment quarterly, or twice in a 6-month period. Average the council income over the 6-month period and combine it with the convenience store income to arrive at a consistent monthly premium.

If John’s only employment was attending quarterly council meetings, he would only be considered employed in the months he attends meetings, and the entire payment would be counted in the month received.

See Temp Manual TE09.20 (HCRW: MA-EPD Income Calculation).

Premium payments are applied first to the current month’s premium. DHS applies payments exceeding that amount first to any overdue amounts and then as a credit toward future premiums.

Premiums may be refunded to enrollees with a credit balance if:

• The enrollee has died. The enrollee’s estate will receive the refund.

OR

• MA-EPD coverage is terminated.

OR

• The enrollee has entered a long term care facility and is expected to remain for at least 30 consecutive days.

If any of the above conditions apply, send MAXIS E-mail to mail group MADE. If there is a credit balance, DHS will issue a refund within 60 days.

See §0913.02 (Premium Payment Options) for information on acceptable premium payment methods and procedures for dishonored payments.

GAMC:

No provisions.

Return to Top

PREMIUM PAYMENT OPTIONS 0913.02

MinnesotaCare:

People may pay premiums by:

• Check or money order. Treat payments made with dishonored checks as failure to pay. See §0913 (Premiums and Spenddowns). • Automatic withdrawal plan (AWP). Enrollees may choose to have premiums deducted automatically from their bank accounts on the 10th of each month. To sign up for automatic withdrawal, enrollees must complete the form Automatic Withdrawal Plan (DHS 3389) and send it with a voided check or deposit slip to:

MinnesotaCare Automatic Withdrawal Plan

PO Box 64834

St. Paul, MN 55164-0834

The MinnesotaCare Information form (DHS 3104) and the AWP brochure (DHS 3389) contain information on AWP.

Automatic withdrawal begins approximately 60 days after the enrollee submits the form. Financial Operations Division (FO) sends the enrollee a confirmation letter. Enrollees may end AWP at any time. Financial Operations will stop AWP when they receive a request or if there is no bill generated. If no bill is generated because the enrollee’s renewal is received late, FO will stop AWP. The enrollee must pay premiums using another mechanism until they again sign up for AWP.

• Through the DHS Web site at www.MinnesotaCare411.com. Enrollees should click on the link "Pay your MinnesotaCare Premium Online here." They will need their case number and invoice number. Enrollees may make online payments by:
• Visa or MasterCard. Enrollees will need to enter the card number, 3-digit security code on the back of the card (Visa only), and card expiration date.

OR

• Checking account. Enrollees will need to enter the bank routing number and checking account number.

Online payments made by 5:00 PM on a business day will be credited that day. Online payments made after 5:00 PM on a business day or on weekends and holidays will be credited the next business day.

MA:

After the county collects the initial premium and SRU assigns an invoice number, people may pay premiums for the MA-EPD program by:

• Personal or cashier’s check • Money order • Automatic withdrawal plan (AWP). Enrollees may choose to have premiums deducted automatically from their bank accounts each month. To sign up for the automatic withdrawal, enrollees must complete the form Automatic Withdrawal Plan (DHS 3389) and send it with a voided check or deposit slip to:

DHS - Automatic Withdrawal Plan

PO Box 64834

St. Paul, MN 55164-0834

Automatic withdrawal begins approximately 60 days after the enrollee submits the form. Financial Operations (FO) sends the enrollee a confirmation letter. Enrollees may end AWP at any time. Financial Operations will stop AWP when they receive a request or if there is no bill generated. If AWP is stopped, the enrollee must pay premiums using another mechanism until they again sign up for AWP.

• Credit card--Visa or MasterCard.

• Bank debit card with a VISA logo.

To pay by credit or debit card, instruct clients to call 651-431-3355 or 1-888-234-1321.

Consider payment with a dishonored personal check or automatic withdrawal to be failure to pay the premium by the due date. The enrollee must replace the dishonored payment with a guaranteed form of payment (cashier’s check or money order). See §0915.11 (Fail to Pay Premium/Voluntary Cancellation).

GAMC:

No provisions.

Return to Top

PREMIUM REFUNDS 0913.02.03

MinnesotaCare:

When canceling coverage, check financial control to see if the household has a credit balance or has paid for a future month for which they will not receive coverage. If the household has a credit or will have one because of the cancellation, track and submit a refund request to the MMIS User Services Help Desk 31 days after the payment was posted.

EXCEPTION:

Workers may request refunds for payments made by cash, money order, or cashier’s check any time after the payment is posted without waiting 31 days. Contact the MMIS User Help Desk if you are unsure what payment method was used.

People cannot receive a refund for any month for which a capitation payment has been made.

See MMIS User Manual MC-VII-1-2 for refund instructions.

DHS Financial Operations issues refund checks every 2 weeks to the provider listed on the MinnesotaCare case. Contact the household to confirm the mailing address before requesting a refund. Enter the contact and the refund request in case notes. Households will receive refunds 2-4 weeks after the worker submits the refund request.

MMIS issues a monthly report of closed cases with credits. The MMIS User Services Help Desk will notify workers to review cases with credits of $100 or more. Verify the mailing address and initiate a refund if appropriate. Do not request refunds for cases for which you are unable to confirm the current mailing address.

Generally, credits on active cases will be applied against future billings. If an active enrollee requests a refund of credit balances, submit and track a refund request following the procedures in this section.

MA:

See 0913.01.03 (MA-EPD Premiums).

GAMC:

No provisions.

Return to Top

SPENDDOWNS -- MA/GAMC 0913.03

MinnesotaCare:

See §0913 (Premiums and Spenddowns).

MA:

People whose income is equal to or less than the applicable income standard are eligible without a spenddown. See §0912.07 (Income Standards).

People with income in excess of the applicable standard may be eligible by spending down to the standard. Spending down means incurring medical expenses equal to or greater than the difference between countable income and the income standard.

First compare household income to the appropriate Federal Poverty Guidelines (FPG) income standard to determine if there is eligibility without a spenddown.

See the income standards in the following sections:

§0912.07.275 275 Percent of FPG Standards.

§0912.07.280 280 Percent of FPG Standards.

§0912.07.150 150 Percent of FPG Standards.

§0912.07.100 100 Percent of FPG Standards.

§0912.07.075 75 Percent of FPG Standards.

People whose income is equal to or less than the FPG standard applicable to their program and basis of eligibility are eligible without a spenddown. For people whose income exceeds the FPG standard, determine if they can meet a spenddown. The spenddown standard for Method A is 100% of FPG regardless of age or pregnancy. See §0912.07.05 (100 Percent of FPG). The spenddown standard for MA Method B and all GAMC is 75% of FPG. See §0912.07.075 (75 Percent of FPG).

EXAMPLE:

Beth applies for MA for her 16-year-old son Thomas. Countable income exceeds 150% of FPG (the appropriate standard for a child under age 18 on Method A) for a household of 2.

Because income exceeds the 150% FPG standard, Thomas is not eligible without a spenddown. You must determine if he can meet a spenddown using the 100% of FPG standard.

There are no spenddown provisions for:

• Transitional/Transition Year MA (TMA/TYMA). See §0907.19.11 (Transitional/Transition Year MA). There is no income limit for the first 6 months of eligibility. The income limit for the second 6 months is 185% FPG. See §0912.07.185 (185 Percent of FPG Standards). People whose income exceeds the limit for the 2nd 6 months are no longer eligible for TYMA. Redetermine eligibility under another basis. • QMB, SLMB, QWD and QI. See §0907.21.09 (MA Basis: Medicare Supplement Programs). Income must be within the applicable standards for QMB, SLMB, QWD, or QI benefits. People with income in excess of these standards are not eligible for these programs. They may be eligible for MA if they meet a spenddown based on the 75% of FPG standard. See §0912.07.075 (75 Percent of FPG). • Pregnant women from the month they are found eligible under the 275% of FPG standard through the 60-day postpartum period. See §0907.19.05 (MA Basis: Pregnant Women). • Infants eligible as auto newborns through the month of their 1st birthdays. See §0907.19.05.03 (MA Basis: Auto Newborn).

Determine eligibility for a 6-month income certification period. See §0905.09 (6-Month Reporting). The client does not have to meet the spenddown in all 6 months. The certification period does not have to include the month of application.

EXAMPLE:

Joel applies for MA for himself and his family in May. He was laid off and received his final pay checks in May. He will begin receiving Unemployment Insurance in June. His income for May would result in a spenddown on both a monthly and 6-month basis. The family has no bills to meet the spenddown. Anticipated income for June-November results in no spenddown. Approve the May application for the certification period June-November if the family meets all other eligibility factors.

EXAMPLE:

Midge applies for MA for her husband, Ike, on November 21. Ike is entering an LTC on November 22 and will need MA effective December 1. If all eligibility factors are met, verify Ike’s entry into the LTC and approve MA effective December 1. The 6-month certification period is December-May.

See the following sections for instructions on calculating the spenddown:

§0913.07 6-Month Spenddown Calculation.

§0913.09 Automated Monthly Spenddown Calculation.

§0913.11 Manual Monthly Spenddown Calculation.

§0913.13 Long Term Care Spenddown Calculation.

§0913.15 Combination LTC/Medical Spenddown.

In some cases people have a choice of spenddown type. See §0913.05 (Which Spenddown Type to Use), §0913.05.03 (Use of MA Monthly Spenddown), and §0913.05.05 (Use of 6-Month and LTC Spenddowns). People must use the same spenddown type throughout a certification period unless they become subject to a long term care spenddown. For information about LTC spenddowns, see:

§0913.17 Begin/End Use of LTC Spenddown - Part 1.

§0913.17.01 Begin/End Use of LTC Spenddown - Part 2.

§0913.17.03 Begin/End Use of LTC Spenddown - Part 3.

§0913.19 Shortened Spenddown.

For deceased clients, use a shortened income certification period beginning with the month of application or the 1st retroactive month and ending with the month of death. See §0913.19 (Shortened Spenddown).

Deduct allowable health care expenses from excess income following the order in §0913.21 (Allowable Medical Bills to Meet Spenddown). On the date medical bills equal the client's excess income, the client has met the spenddown and is income eligible. If clients must use medical bills for an asset reduction as well as a spenddown, complete the asset reduction first. See §0909.29 (Excess Assets - Applicants) and §0909.29.03 (Excess Assets -Enrollees).

GAMC:

No provisions.

Return to Top

WHICH SPENDDOWN TYPE TO USE 0913.05

MinnesotaCare:

No provisions.

MA:

Most clients who do not live in an LTCF or get LTC home-based services may choose which spenddown method to use. Some people may be eligible for more than one spenddown type. Help clients who could meet both a 1-month and a 6-month spenddown determine which method would result in the lower client obligation for the 6-month income certification period. You may need to determine what the spenddown amount would be on both a monthly and a 6-month basis to help the client make the best choice. Some clients may have a monthly spenddown but be eligible without a 6-month spenddown or vice versa because of changes in age, household size, income, or income deductions anticipated during the certification period.

EXAMPLE:

Mark, age 20, and his wife Melissa, age 19, apply for MA for themselves in October. They are not requesting retroactive coverage. Melissa has no income. Mark is receiving Reemployment Insurance which will end in mid-December. Anticipated income for October and November exceeds the income standard. Anticipated income for December-March is less than the income standard. Total anticipated income for October-March is less than the 6-month income standard. Advise Mark and Melissa that they are eligible without a 6-month spenddown.

EXAMPLE:

Fred applies for MA for his son Ben, age 14, in October. He requests MA retroactive to July. Fred is employed and had net income of $1,500 per month in July, August, September and October. His net income is anticipated to increase to $1,600 per month in November and December. Ben has no income. Ben's income standard is 150% FPG ($1,562 per month effective July 1, 2004). His monthly income is less than the standard for July-October but exceeds the standard for November and December. Anticipated income for the 6-month certification period totals $9,200, which is less than the 6-month standard of $9,372. Ben is eligible without a spenddown for July-December. If anticipated income continues to exceed the standard at the time of the 6-month review, Ben will have a spenddown for the next certification period (January-June).

Clients do not have to meet both a 6-month and a 1-month spenddown to be eligible for MA. However, they must use the same spenddown type for the entire 6-month income certification period.

Apply the following guidelines to people who live in the community and do not get home care services through Elderly Waiver:

• Spouses who live together or parents and children who live together must use the same type of spenddown. If some household members have no spenddown for the 6-month certification period, other household members may choose either a 6-month or a monthly spenddown. All household members who have spenddowns must choose the same spenddown type.

EXAMPLE:

Merrillee and Don apply for MA for themselves and their two children, ages 3 and 4. All household members meet an MA basis of eligibility. See §0907.17 (MA/GAMC Bases of Eligibility). The children have an income standard of 150% FPG. See §0912.07.150 (150 Percent of FPG Standards). Merrillee and Don have an income standard of 100% of FPG. See §0912.07.100 (100 Percent of FPG). Countable income for the 6-month certification period is less than the children’s standard but exceeds the standard for Merrillee and Don. The children have no spenddown. Merrillee and Don may choose either a 6-month or a 1-month spenddown. Both must use the same spenddown type.

For clients who choose a monthly spenddown, determine whether they must use an automated monthly or manual monthly spenddown.

Also see §0913.05.03 (Use of MA Monthly Spenddown), §0913.05.05 (Use of 6-Month and LTC Spenddowns).

GAMC:

No provisions.

Return to Top

USE OF MA MONTHLY SPENDDOWN 0913.05.03

MinnesotaCare:

No provisions.

MA:

Also see §0913.05 (Which Spenddown Type to Use).

Clients MAY use an automated monthly spenddown if:

• Their income does not vary.

AND

• They have regular monthly medical expenses, and the expenses used to meet the spenddown are health insurance premiums, expenses payable through MMIS, or allowable remedial care costs for clients in GRH facilities. Refer to Instructional Bulletin #94-22B for more information on allowable remedial care costs. Verify that a GRH client is reasonably certain to remain in the GRH setting for the full month.

EXAMPLE:

Nanette, age 67, lives alone in the community. She receives gross RSDI of $800 per month. She is eligible for payment of her Medicare Part B premium through SLMB and is enrolled in PDP. She has a monthly MA spenddown of $298, which she meets with a combination of regular prescriptions and therapy co-payments remaining after Medicare pays. She is eligible for an automated monthly spenddown because she has unvarying income and regular medical expenses payable through MMIS.

Clients MUST use an automated monthly spenddown if:

• They choose the Client Option or Designated Provider spenddown. See §0913.09.03 (Client Option Spenddown) and §0913.09.05 (Designated Provider Option).

OR

• Their spouse or children with whom they live apply for MA and choose an automated monthly spenddown.

OR

• They were hospitalized and are members of a family enrolled in MinnesotaCare. See TEMP Manual TE11.011 (Inpatient Hospital Referrals to MA) and §0913.21.07 (MinnesotaCare Inpatient Hospitalization).

See §0913.09 (Automated Monthly Spenddown Calculation) for instructions on calculating the spenddown.

Clients MAY use a manual monthly spenddown if they are not members of a family on MinnesotaCare who have been hospitalized AND:

• Their income varies. This includes situations in which net income varies during a certification period due to changes in disregards or deductions.

OR

• Their medical expenses vary.

OR

• Their medical expenses are non-reimbursable by MA/GAMC.

EXAMPLE:

Phoebe applies for MA for herself and her two children. She is employed part- time and receives child support for the children sporadically. Total income for each family member exceeds the applicable standard on both a monthly and 6-month basis. Phoebe incurred medical bills in the month of application which exceed the monthly spenddown amount but are less than the 6-month spenddown. Use a monthly manual spenddown.

Clients MUST use a manual monthly spenddown if:

• Their spouse or children who are applying for MA choose a manual monthly spenddown.

OR

• Their spenddown is met, in whole or in part, with bills paid by MinnesotaCare for other family members. Bills paid by MinnesotaCare for people for whom DHS receives FFP cannot be used to meet an MA spenddown for other family members. See §0913.21.05 (MinnesotaCare Expenses to Meet Spenddown). See Temp Manual TE02.07.304 and TE02.07.305 (MinnesotaCare and MA Spenddowns - Parts 1 and 2) for MAXIS instructions.

Also see §0913.05.05 (Use of 6-Month and LTC Spenddowns).

GAMC:

No provisions.

Return to Top

USE OF 6-MONTH AND LTC SPENDDOWNS 0913.05.05

MinnesotaCare:

No provisions.

MA:

Also see §0913.05 (Which Spenddown Type to Use) and §0913.05.03 (Use of MA Monthly Spenddown).

Anyone who is not required to use a monthly automated or manual spenddown may choose a 6-month spenddown. Eligibility for clients who choose a 6-month spenddown begins on the day medical bills equal or exceed the spenddown amount and continues for the rest of the income certification period, unless the client reports a change (such as increased income) that requires you to recalculate eligibility. Any client not specifically required to use a monthly spenddown may choose a 6-month spenddown. See §0913.07 (6-Month Spenddown Calculation) for instructions on calculating the spenddown.

Follow the instructions below for people living in LTCFs or receiving home care services through the Elderly Waiver (EW).

Long Term Care:

• Clients who do not have a community spouse and who live in an LTCF for a minimum of 30 consecutive days must use an LTC spenddown. See CONTINUOUS PERIOD OF INSTITUTIONALIZATION in §0902.07 (Glossary: Client...) for instructions on determining 30 consecutive days. Enter the spenddown data in MMIS using an institutional spenddown type. • Clients who have a community spouse and who are expected to live in an LTCF for a minimum of 30 consecutive days must use an LTC spenddown. Enter an institutional spenddown type on MAXIS. • Residents of MA certified LTCFs whose LTC spenddown amount is more than the monthly LTCF costs must use a combination spenddown. See §0913.15 (Combination LTC/Medical Spenddown). • Residents of non-MA certified LTCFs can choose a 6-month or a 1-month medical spenddown. • Clients who live in an LTCF and receive QMB-only may NOT use a LTC spenddown even if they are likely to stay in the LTCF for 30 or more days. Enter an LTCF living arrangement on the STAT/FACI panel in MAXIS and on the RLVA screen in MMIS.

Elderly Waiver (EW):

• Clients whose income is less than the Special Income Standard (SIS) do not have a spenddown. They have a monthly waiver obligation if their income exceeds the maintenance allowance. For more information see:

SPECIAL INCOME STANDARD (SIS) in §0902.37 (Glossary: Sole...)

MAINTENANCE NEEDS ALLOWANCE in §0902.21 (Glossary: Insurance...)

§0913.13.05 (Waiver Obligation--SIS EW).

• Clients who are not eligible for SIS EW, have a community spouse and are expected to receive home care services through EW for at least 30 consecutive days must use an LTC spenddown. See CONTINUOUS PERIOD OF INSTITUTIONALIZATION in §0902.07 (Glossary: Client...) for instructions on determining 30 consecutive days. Enter a monthly automated spenddown type and method on MMIS. • EW clients who are required to use an LTC spenddown as described above must use a combination spenddown if the LTC spenddown amount is more than the cost of home care services provided through EW. See §0913.15 (Combination LTC/Medical Spenddown). If clients have medical costs beyond the home care services sufficient to meet their spenddown, enter the full amount as a medical spenddown on MMIS. • Clients who are not eligible for SIS EW, do not have a community spouse and who get home care services through EW must use a monthly or 6-month medical spenddown.

When a married couple both receive waivered services, determine eligibility and spenddown amount separately for each spouse using a household size of 1.

GAMC:

No provisions.

Return to Top

6-MONTH SPENDDOWN CALCULATION 0913.07

MinnesotaCare:

No provisions.

MA:

Applicants can request eligibility for the month of application and the retroactive month(s). Retroactive coverage is available for 3 months before the month of application for MA and one month before the month of application for GAMC. See §0904.07.09 (Eligibility Begin Date).

Eligibility begins on the day incurred medical expenses equal or exceed the 6-month spenddown amount. Eligibility continues through the last day of the 6-month certification period. Clients must meet the spenddown by the end of the application month OR the date you process the application, whichever is later.

EXAMPLE:

Brad applies for MA on February 23. He is requesting retroactive coverage for January. He submits all verifications on March 5. The worker completes the eligibility determination on March 10. Brad met his 6-month spenddown on March 3. Approve eligibility effective March 3 for the certification period January-June.

Do not anticipate medical bills the client has not yet incurred when determining whether the client meets the spenddown.

EXAMPLE:

Sherita applies for MA on July 15. She does not have enough bills to meet her spenddown in July, but plans to fill a monthly prescription on August 1. Because this is within the 45-day processing period, it is possible to approve the application with an August effective date. Do not approve eligibility until Sherita verifies the August 1 charge.

To calculate the spenddown for applicants:

1. Enter income information on the appropriate MAXIS STAT panel. Enter the anticipated income in the HC Income Estimate window in the current month plus one, benefit month. See §0911.11.03 (Computing Countable Income – MA/GAMC) for instructions on determining the anticipated income. If retroactive eligibility has been requested, update STAT/HCRE. The retroactive months will need to be FIATed in ELIG/HC using the actual income received during the retroactive months. See TEMP Manual TE09.17.02 (HCRW: FIAT).

2. Enter gross and net amounts of verified medical expenses in MAXIS on the STAT/BILS panel. See §0913.21 (Allowable Medical Bills to Meet Spenddown), §0913.21.03 (Determining Net Medical Expenses) and TEMP Manual TE09.07.02 (HCRW: STAT/BILS).

3. MAXIS will calculate the spenddown based on the information that is entered in STAT. After background has run, review the budget in ELIG/HC. From the BSUM panel select MOBL and SPDN to review the spenddown calculation. See TEMP Manual TE09.18 (HCRW: Retro Processing) if there is a need to FIAT due to retroactive eligibility.

4. Enter the appropriate information on MMIS. See MMIS User Manual II-23 (Six-Month Spenddown).

To calculate the spenddown at the time of the 6-month income review or annual recertification:

1. Do not take a new application when the income certification period expires. Use the income review due in the 5th month to determine continued eligibility for the next 6-month certification period. Verify the amount of any health insurance premiums that are due on the first day of the next review period, even if they were paid during the last 3 months of the current review period. Also verify any non-MA reimbursable expenses incurred in the last 3 months of the current period and any unpaid medical expenses incurred before the current certification period that were not used to meet a previous spenddown. See §0913.21 (Allowable Medical Bills to Meet Spenddown).

Clients must provide verification of current income and medical expenses to be applied to the next 6-month period by the last day of the current 6-month review period.

2. Enter income information on the appropriate MAXIS STAT panel. Enter the anticipated income in the HC Income Estimate window in the current month plus one, benefit month. See TEMP Manual TE09.26.01 (HCRW: Processing Health Care Renewals). See §0911.11.03 (Computing Countable Income – MA/GAMC) for instructions on determining the anticipated income. Enter the gross and net amounts of verifiable medical expenses in MAXIS on the STAT/BILS panel.

3. MAXIS will calculate the spenddown type and amount based on the information that is entered in STAT. See TEMP Manual TE09.13.06 (HCRW: Determining Community Spenddown Type). After background has run, review the budget in ELIG/HC. From the BSUM panel select MOBL and SPDN to review the spenddown calculation.

4. Enter the appropriate information on MMIS. See MMIS User Manual II-23 (Six-Month Spenddown). If eligibility continues, schedule an income or eligibility review for the 5th month of the next review period. See §0905.09 (6-Month Reporting).

If clients cannot meet the new spenddown, terminate the case at the end of the 6-month income review period. Advise clients to reapply if they incur new medical expenses or have a change in income. The MAXIS termination notice advises them of the availability of MinnesotaCare.

GAMC:

No provisions.

Return to Top

AUTOMATED MONTHLY SPENDDOWN CALCULATION 0913.09

MinnesotaCare:

No provisions.

MA:

Clients can request eligibility for the month of application and the retroactive month(s). Retroactive coverage is available for 3 months before the month of application for MA. See §0904.07.09 (Eligibility Begin Date).

Determine eligibility separately for each month. If clients are eligible in the month of application or any of the retroactive months, the case remains open for the rest of the 6-month certification period, if the client meets all other eligibility factors.

To calculate the spenddown for applicants:

1. Enter income information on the appropriate MAXIS STAT panel. Enter the anticipated income in the HC Income Estimate window in the current month plus one, benefit month. See §0911.11.03 (Computing Countable Income – MA/GAMC) for instructions on determining the anticipated income. If retroactive eligibility has been requested, update STAT/HCRE. The retroactive months will need to be FIATed in ELIG/HC using the actual income received during the retroactive months. See TEMP Manual TE09.17.02 (HCRW: FIAT).

2. Enter the gross and net amounts of verifiable medical expenses in MAXIS on the STAT/BILS panel. See §0913.21 (Allowable Medical Bills to Meet Spenddown), §0913.21.03 (Determining Net Medical Expenses) and TEMP Manual TE09.07.02 (HCRW: STAT/BILS). If the client expects to pay Medicare premiums each month and you are not using an LTC budget, enter the Medicare premium as an expense on the STAT/BILS panel for each month of the income certification period. Use actual dollars and cents (use the gross amount; do not round or truncate). Also enter health insurance premiums if they are paid on a monthly basis rather than on a quarterly basis or some other interval. If health insurance premiums are not paid monthly, do not enter them as an automated monthly spenddown expense.

If a client using an LTC budget expects to pay Medicare premiums each month, indicate that on STAT/MEDI.

3. MAXIS will calculate the spenddown type and amount based on the information that is entered in STAT. See TEMP Manual TE09.13.06 (HCRW: Determining Community Spenddown Type). After background has run, review the budget in ELIG/HC. From the BSUM panel select MOBL and SPDN to review the spenddown calculation.

4. Enter the appropriate information in MMIS. Do not enter a satisfaction date. See MMIS User Manual II-25 (Automated Monthly Spenddown).

5. MAXIS anticipates income for the remaining months of the review period from the information entered in the HC Estimate window on the appropriate STAT income panel. Do not verify income and medical expenses monthly. Schedule an income review for completion during the 5th month of the review period. Tell the client to report any changes. See §0905.09 (6-Month Reporting). Unless income changes, MMIS continues the current spenddown amount for the remainder of the 6-month review period.

To calculate the spenddown at the time of the 6-month income review or annual recertification:

1. Do not take a new application when the 6-month certification review period expires. Use the income review in the 5th month as a guide to determine continued eligibility for the next period. Also request verification of medical expenses incurred in the 5th month or review the RSPD and RSLG screens in MMIS for the 5th month to determine if the spenddown was met.

2. Enter the income and medical expenses on STAT using the information from the review and your best estimate of the client's income and expenses for the new certification period. If the client wants to switch spenddown methods, see §0913.07 (6-Month Spenddown Calculation), §0913.11 (Manual Monthly Spenddown Calculation) and TEMP Manual TE09.13.10 (HCRW: How to Change Spenddown Type). Clients must use a manual monthly medical spenddown if they still want a monthly spenddown, but their income or medical expenses now vary.

3. If MAXIS determines that the client will continue to meet a spenddown in the next period, extend eligibility for another 6-month period. MAXIS will use anticipated income entered in the HC Estimate window on the income panels in STAT for the next period. An income or eligibility review for the 5th month of the next review period. See §0905.09 (6-Month Reporting).

If MAXIS determines that the client is unlikely to meet a spenddown in the next certification period using any spenddown method, close the case at the end of the 6-month income certification period. Advise clients to reapply if they incur new medical expenses or have a change in income. The MAXIS termination notice advises them of the availability of MinnesotaCare.

Clients eligible for an automated monthly spenddown may choose to pay their spenddown obligation to DHS or to a specific provider. See §0913.09.03 (Client Option Spenddown).

Clients who receive personal care attendant services, certain waivered services, or child welfare targeted case management services may choose to pay their spenddown to a designated provider. See §0913.09.05 (Designated Provider Option).

GAMC:

No provisions.

Return to Top

CLIENT OPTION SPENDDOWN 0913.09.03

MinnesotaCare:

No provisions.

MA:

Clients eligible for an automated monthly spenddown may choose to prepay their spenddown to DHS. This is called client option spenddown. The client option spenddown cannot be used with the 1-month manual, 6-month, or LTC spenddowns. It can only be used with the 1-month automated spenddown.

Clients who have a waiver obligation under the SIS EW program and Prescription Drug enrollees may not use the client option spenddown. See §0913.13.05 (Waiver Obligation--SIS EW) and §0907.21.09.11 (Medicare Supplement Programs: PDP).

Explain the client option spenddown to clients who ask about it or who may benefit from using the option. Give the client a copy of the Agreement to Prepay Medical Assistance (MA) Spenddown (DHS 3081) to read and sign. Retain a copy of the signed agreement in the case file.

Begin the client option spenddown the month after the client completes the DHS 3081. MMIS will send the frst monthly bill when client option case data is entered on or before the 15th day of the initial request month. County agencies must send the first bill when client option case data is entered on MMIS after the 15th day of the initial request month. Use the Client Option Spenddown Bill (DHS 3180). MMIS will send subsequent bills.

See the MMIS User Manual (Client Option Spenddown) for instructions on opening client option spenddown cases on MMIS.

Clients must pay their spenddown to DHS by the 20th of the preceding month. See MMIS User Manual II-32 (Client Option Spenddown: Billing Cycle and Client Option Payments) for information on payments received after the 20th of the month.

Late payment, non-payment, or partial payment does not affect the client's eligibility for MA, nor does it result in a loss of the client option spenddown. However, clients who send personal checks with non-sufficient funds will be terminated from client option spenddown and must pay the full amount of the NSF check and the next month’s payment with a money order or cashier's check before they can be reinstated on the client option spenddown.

If the amount of the client's spenddown changes, MMIS will send a bill for the new amount.

GAMC:

No provisions.

Return to Top

DESIGNATED PROVIDER OPTION 0913.09.05

MinnesotaCare:

No provisions.

MA:

Some clients may designate one provider to whom they will pay their spenddown each month. Clients using the long term care (LTC) spenddown must use this option. Other clients may choose this option if they meet ALL the following conditions:

• They have a 1-month automated spenddown.

AND

• They receive Personal Care Attendant (PCA) services, child welfare targeted case management services, or receive services through one of the following home and community based waivers: Elderly Waiver (EW), Community Alternatives for Disabled Individuals (CADI), Traumatic Brain Injury (TBI), Community Alternative Care for Chronically Ill Individuals (CAC), or Home and Community Based Services for Persons with Mental Retardation or Related Conditions (MR/RC).

AND

• They are the only members of the MA/GAMC household with a spenddown.

AND

• They can meet their entire spenddown with one designated provider. Verify that clients have met their spenddown with the designated provider for the last 3 months and expect to continue to do so.

AND

• They are willing to pay the spenddown amount to the designated provider at the time they receive services. Past payment history or other factors must indicate a strong likelihood that clients will cooperate in paying the spenddown.

Clients who have a waiver obligation under the SIS EW program may use the designated provider option beginning with the month following the month in which eligibility is approved. The designated provider option cannot be added, changed or deleted for a current or retroactive month, including the month of application. SIS EW clients who choose this option must select a waivered service provider as the designated provider. See §0913.13.05 (Waiver Obligation--SIS EW).

Clients who choose the designated provider option must sign the Agreement to Use Designated Provider (DHS 3161). Refer to the MMIS User Manual II-31 (Designated Provider) for instructions on entering designated provider cases on MMIS. Providers cannot refuse to be designated providers.

Clients can meet their spenddown using a provider other than the designated provider only in emergencies. Clients must report emergency use within 5 days of incurring the expense. Send the information below to the DHS Special Recovery Unit by MAXIS E-Mail to COSD or by FAX to 651-282-6744.

• The client's full name. • Mailing address. • PMI number. • Dates of service • The name(s) of the provider used instead of the designated provider.

SRU will monitor these cases and may bill the client for any unmet spenddown balance for the given month. They will also monitor all designated provider cases to make sure that the provider submits bills within 3 months and that the client incurs enough bills to meet the spenddown.

If the provider indicates that a client has refused or failed to pay the spenddown, remove the client from the designated provider option.

GAMC:

No provisions.

Return to Top

MANUAL MONTHLY SPENDDOWN CALCULATION 0913.11

MinnesotaCare:

No provisions.

MA:

Clients can request eligibility for the month of application and the retroactive month(s). Retroactive coverage is available for 3 months before the month of application. See §0904.07.09 (Eligibility Begin Date).

Determine eligibility separately for each month of the 6-month certification period. Eligibility may be intermittent during the certification period. If clients are eligible in the month of application or any of the retroactive months, approve the case on a 6-month certification period beginning with the first month of eligibility. Determine eligibility for every month in the 6-month period. Do not terminate MA before the end of the 6-month period even if available information indicates the client will not meet a spenddown in the remaining months.

EXAMPLE:

Bill applies for MA on November 28. His income exceeds the standard for both a 6-month and a monthly spenddown. He incurred a large hospital bill and related charges earlier in November. The total expenses exceed the monthly spenddown amount for November. Bill selects a monthly spenddown. Leave the case open for the entire 6-month period regardless of whether Bill meets the spenddown in subsequent months.

To calculate the spenddown for applicants:

1. Enter income information on the appropriate MAXIS STAT panel. Enter the anticipated income in the HC Income Estimate window in the current month plus one, benefit month. See §0911.11.03 (Computing Countable Income – MA/GAMC) for instructions on determining the anticipated income. If retroactive eligibility has been requested, update STAT/HCRE. The retroactive months will need to be FIATed in ELIG/HC using the actual income received during the retroactive months. See TEMP Manual TE09.17.02 (HCRW: FIAT).

2. Enter the gross and net amounts of verifiable medical expenses in MAXIS on the STAT/BILS panel. See §0913.21 (Allowable Medical Bills to Meet Spenddown), §0913.21.03 (Determine Net Medical Expenses), and TEMP Manual TE09.07.02 (HCRW: STAT/BILS).

3. MAXIS will calculate the spenddown type and amount based on the information that is entered in STAT. See TEMP Manual TE09.13.06 (HCRW: Determining Community Spenddown Type). After background has run, review the budget in ELIG/HC. From the BSUM panel select MOBL and SPDN to review the spenddown calculation. See TEMP Manual TE09.13.11 (HCRW: Manual Monthly Spenddown: Applicants).

4. Enter the appropriate information on MMIS. See MMIS User Manual II-24 (Manual Monthly Spenddown).

To calculate the spenddown at the time of the 6-month income review or the annual recertification:

1. The client must provide the HRF with income and medical expense verification by the last day of the month after the budget month. See §0905.07 (Monthly Reporting). Clients may meet the spenddown in some months and not in others. Enter the information from the monthly Household Report Form (HRF) on the appropriate STAT panels

2. Follow steps listed in TEMP Manual TE09.13.13 (HCRW: Manual Monthly Spenddown: Renewal/HRF).

3. Do not take a new application when the income certification period expires. During the 6th month, use the information reported on the HRFs for months 1-5 to determine if the client is likely to be able to meet a spenddown in one or more months of the next income certification period. Base this decision on your best estimate of the client's income and medical expenses for the next 6 months. Leave the case open with a manual monthly spenddown if you determine that the client is likely to meet a spenddown in at least one month of the next certification period.

GAMC:

No provisions.

Return to Top

LONG TERM CARE SPENDDOWN CALCULATION 0913.13

MinnesotaCare:

No provisions.

MA:

Before doing a spenddown calculation for months in which clients enter or leave a facility, are in temporary LTCF placement, or begin or end elderly waiver services, see:

§0913.17 (Begin/End Use of LTC Spenddown - Part 1)

§0913.17.01 Begin/End Use of LTC Spenddown - Part 2)

§0913.17.03 Begin/End Use of LTC Spenddown - Part 3).

Review non-varying income, including earned income of long term care residents who routinely earn $80 or less per month, at each annual renewal. See §0905 (Reviews and Renewals).

Review varying income monthly, including earned income of long term care residents who routinely earn more than $80 per month. Make appropriate adjustments to the LTC spenddown. Budget earned and unearned income in the month it is received. Do not average income for clients in LTCFs. Apply changes in income or deductions to the LTC spenddowns in the month the change occurs. Retroactive changes to LTC spenddowns do not require timely notice. See §0916 (Notices).

SPENDDOWN CALCULATION FOR LTCF RESIDENTS:

To calculate the spenddown for people residing in an LTCF in a month the client is subject to LTC budgeting, begin with the total gross unearned income and countable earned income received by the client in that month. Include all excluded and non-excluded types of income except for income tax refunds, homeowner/renter property tax refunds and earned income tax credits.

Calculate countable earned income as follows:

Count all gross earned income or net self-employment income of an LTCF resident unless the resident is disabled and receiving wages from employment under an individual plan of rehabilitation.

Allow disabled people who are receiving wages from employment under an individual plan of rehabilitation the following deductions from gross earned income in the order listed:

1. $80 special personal allowance. See §0912.05.09.07 (Special Personal Allowance Disregard).

2. Actual FICA withheld.

3. Actual transportation expenses.

4. Actual employment expenses such as tools and uniforms.

5. State and federal taxes (only when the person is not exempt from withholding).

Allow the following deductions from the total gross unearned and countable earned income in the order listed:

1. Exclusions from income of institutionalized people mandated under federal law. These exclusions include:

• German Reparation payments • Japanese and Aleutian Restitution payments • Agent Orange Settlement Fund payments • Radiation Exposure payments • payments under the Domestic Volunteer Services Act • payments received under the White Earth Land Settlement Act (WELSA) • Netherlands Act (WUV) payments to victims of Nazi persecution • Vietnamese Commando Compensation payments • payments to children of Viet Nam veterans with spina bifida • Austrian reparation payments • Blood Product Settlement Payments • payments by the Secretary of Defense to people captured and interned by North Vietnam.

VA pensions limited to $90 per month are also excluded as the person’s clothing and personal needs allowance. See §0912.07.03 (Clothing and Personal Need Allowance).

If you are unsure whether a particular payment meets this exclusion, submit a policy interpretation. Include the applicable public law number if known.

2. Medicare premiums of clients who are not Qualified Medicare Beneficiaries (QMBs), Service Limited Medicare Beneficiaries (SLMB's), or Qualified Individuals (QI's). See §0907.21.09 (MA Basis: Medicare Supplement Programs).

3. Clothing and personal needs allowance OR the home maintenance allowance for single residents in a temporary stay situation. See the following:

§0912.07.03 Clothing and Personal Need Allowance.

§0913.17 Begin/End Use of LTC Spenddown - Part 1.

§0913.17.01 Begin/End Use of LTC Spenddown - Part 2.

§0913.17.03 Begin/End Use of LTC Spenddown - Part 3.

4. Guardianship fees to a legally appointed guardian or conservator, or representative payee fees to an appointed representative payee authorized by the Social Security Administration. Allow up to 5% of the client's gross monthly income to a maximum of $100 after totaling all guardianship, conservator, and SSA representative payee fees. Apply the 5%/$100 maximum even if SSA or a court allows a greater amount.

5. Allocation to a community spouse. See §0912.05.25 (Allocations).

6. Court-ordered child support garnished from income up to a maximum of $250 per month per client. First apply part or all of the garnished amount as the allocation to the child(ren). See §0912.05.25.05 (Allocations--Other Relatives). Enter the balance up to the $250 limit in the MAXIS long term care budget guardianship fee field along with any allowable guardianship fee. Apply both current support and arrearages up to the maximum allowed.

7. Allocation to a family member other than a community spouse. See §0912.05.25.05 (Allocations--Other Relatives).

8. Health insurance premiums the client actually incurs in any month.

9. Other reasonable and necessary medical expenses not covered by MA that the client actually incurs during the 6-month certification period.

10. Continued community level SSI benefits paid under section 1611(e)(1)(G) of the Social Security Act which are paid to people who are expected to be institutionalized for a temporary stay of no more than 3 months and who need to continue to maintain a home, for up to 3 months, as verified by the Social Security Administration.

11. Continued community level SSI benefits paid under section 1611(e)(1)(E) of the Social Security Act which are paid to people who were 1619(a) or (b) in the month before the first full month of institutionalization, for up to 2 months, as verified by the Social Security Administration.

The remaining amount is the LTC spenddown. MAXIS calculates the spenddown based on the income and deductions on the long term care spenddown calculation screens. If the LTC spenddown is greater than the monthly cost of long term care, see §0913.15 (Combination LTC/Medical Spenddown).

The LTCF will bill the client or authorized representative for the spenddown amount.

Do not terminate eligibility if the LTCF is not receiving payment from the client or the client's authorized representative. Do not adjust LTCF spenddowns due to non-payment. The county agency can remove a negligent authorized representative and try to find another. If the client fails to make payments, try to find an authorized representative. In either case, make a referral to Social Services if an authorized representative cannot be found. Also see §0904.11 (Authorized Representatives).

GAMC:

No provisions.

Return to Top

LTC SPENDDOWN -- EW WITH COMMUNITY SPOUSE 0913.13.03

MinnesotaCare:

No provisions.

MA:

Follow the procedures in this section ONLY for people who:

• Receive home care services through the Elderly Waiver (EW)

AND

• Who are not eligible for SIS EW (those with income more than the Special Income Standard). See §0913.13.05 (Waiver Obligation--SIS EW) for people who are eligible under the SIS EW, whether or not they have a community spouse.

AND

• Who have community spouses. See COMMUNITY SPOUSE in §0902.07 (Glossary: Client...) for a definition.

For single clients receiving EW who are not eligible under SIS EW, use Method B budgeting with a household size of 1. For a married couple who both receive EW but are not eligible under SIS EW, use Method B budgeting. Determine eligibility separately for each spouse using each spouse’s income and a household size of 1.

Non-SIS EW clients with no community spouse may use a monthly or 6-month spenddown. For people who choose a monthly spenddown, use an automated monthly spenddown if income and medical expenses are non-varying. See §0913.09 (Automated Monthly Spenddown Calculation). EW clients using an automated monthly spenddown may select the designated provider option. See §0913.09.05 (Designated Provider Option). Use a manual monthly spenddown if income or medical expenses vary. See §0913.11 (Manual Monthly Spenddown Calculation).

LTC SPENDDOWN CALCULATION FOR EW CLIENTS WITH COMMUNITY SPOUSES

Before doing a spenddown calculation for months in which clients begin or end EW services, see:

§0913.17 (Begin/End Use of LTC Spenddown - Part 1)

§0913.17.01 (Begin/End Use of LTC Spenddown - Part 2)

§0913.17.03 (Begin/End Use of LTC Spenddown - Part 3).

Review non-varying income every 6 months. See §0905.09 (6-Month Reporting).

Review varying income monthly and make appropriate adjustments to the LTC spenddown. Budget earned and unearned income in the month it is received. Do not average income for clients receiving EW services. Apply changes in income or deductions to LTC spenddowns in the month the change occurs. Retroactive changes to LTC spenddowns do not require timely notice. See §0916 (Notices).

To calculate the spenddown in a month the client is subject to LTC budgeting, begin with the total gross unearned and earned income received by the client in that month. Include all excluded and non-excluded types of income except for income tax refunds, homeowner/renter property tax refunds and earned income tax credits.

If the income is equal to or less than the SIS, the client is eligible for the SIS EW program. Use LTC budgeting to calculate a waiver obligation according to §0913.13.05 (Waiver Obligation--SIS EW).

If income exceeds the SIS, continue with the following calculations.

Calculate countable earned income as follows:

Count all gross earned income or net self-employment income of a client unless the client is disabled and receiving wages from employment under an individual plan of rehabilitation.

Allow disabled people who are receiving wages from employment under an individual plan of rehabilitation the following deductions from gross earned income in the order listed:

1. $80 special personal allowance. See §0912.05.09.07 (Special Personal Allowance Disregard).

2. Actual FICA withheld.

3. Actual transportation expenses.

4. Actual employment expenses such as tools and uniforms.

5. State and federal taxes (only when the person is not exempt from withholding).

Allow the following deductions from the total gross unearned and countable earned income in the order listed:

1. Exclusions from income of institutionalized people mandated under federal law. These exclusions include:

• German Reparation payments • Japanese and Aleutian Restitution payments • Agent Orange Settlement Fund payments • Radiation Exposure payments • payments under the Domestic Volunteer Services Act • payments received under the White Earth Land Settlement Act (WELSA) • Netherlands Act (WUV) payments to victims of Nazi persecution • Vietnamese Commando Compensation payments • payments to children of Viet Nam veterans with spina bifida • Austrian reparation payments • Blood Product Settlement Payments • payments by the Secretary of Defense to people captured and interned by North Vietnam.

VA pensions limited to $90 per month are also excluded as the person’s clothing and personal needs allowance. See §0912.07.03 (Clothing and Personal Need Allowance).

If you are unsure whether a particular payment meets this exclusion, submit a policy interpretation. Include the applicable public law number if known.

2. Medicare premiums of clients who are not Qualified Medicare Beneficiaries (QMBs), Service Limited Medicare Beneficiaries (SLMB's), or Qualified Individuals (QI). See §0907.21.09 (MA Basis: Medicare Supplement Programs).

3. Clothing and personal needs allowance. See §0912.07.03 (Clothing and Personal Need Allowance).

4. Guardianship fees to a legally appointed guardian or conservator, or representative payee fees to an appointed representative payee authorized by the Social Security Administration. Allow up to 5% of the client's gross monthly income to a maximum of $100 after totaling all guardianship, conservator, and SSA representative payee fees. Apply the 5%/$100 maximum even if SSA or a court allows a greater amount.

5. Allocation to a community spouse. See §0912.05.25.03 (Allocations--Community Spouse).

6. Court-ordered child support garnished from income up to a maximum of $250 per month per client. First apply part or all of the garnished amount as the allocation to the child(ren). See §0912.05.25.05 (Allocations--Other Relatives). Enter the balance up to the $250 limit in the MAXIS long term care budget guardianship fee field along with any allowable guardianship fee. Apply both current support and arrearages up to the maximum allowed.

7. Allocation to a family member other than a community spouse. See §0912.05.25.05 (Allocations--Other Relatives).

8. Reasonable and necessary medical expenses not covered by MA, including any health insurance premiums the client actually incurs in any month.

The remaining amount is the LTC spenddown. If the LTC spenddown is more than the cost of monthly elderly waiver services, see §0913.15 (Combination LTC/Medical Spenddown).

GAMC:

No provisions.

Return to Top

WAIVER OBLIGATION -- SIS EW 0913.13.05

MinnesotaCare:

No provisions.

MA:

People with income equal to or less than the Special Income Standard (SIS) are eligible for the SIS EW program. See §0907.23.11 (MA Waiver Programs: EW).

Follow the steps below to determine eligibility under SIS EW:

1. Total all gross earned and unearned income of the EW applicant or enrollee. Include excluded and non-excluded types of income. Do not include spousal income.

2. Compare the result to the SIS. See SPECIAL INCOME STANDARD in §0902.37 (Glossary: Sole...). The SIS for 1-1-06 through 12-31-06 is $1,809. The SIS for 1-1-05 through 12-31-05 is $1,737.

If the EW applicant or enrollee’s income exceeds the SIS, the person is not eligible for SIS EW. Determine eligibility using a community or LTC spenddown, depending on whether the person has a community spouse. See §0913.05.05 (Use of 6-Month and LTC Spenddowns).

If income is equal to or less than the SIS, proceed to step 3.

3. Allow the deductions from income listed in §0913.13 (Long Term Care Spenddown Calculation).

EXCEPTION:

Instead of the clothing and personal needs allowance or maintenance of home allowance in item 3, deduct the SIS EW maintenance needs allowance.

See MAINTENANCE NEEDS ALLOWANCE in §0902.21 (Glossary: Insurance...). The maintenance needs allowance for 7-1-06 through 6-30-07 is $816. The maintenance needs allowance for 7-1-05 through 6-30-06 is $789.

The result is the EW applicant or enrollee’s monthly waiver obligation. See WAIVER OBLIGATION in §0902.41 (Glossary: Underinsured...). If there is no income remaining after allowable deductions, the person is eligible for EW with no spenddown or waiver obligation.

SIS EW clients do not have to meet the waiver obligation in full each month to remain eligible. Enrollees whose monthly waiver costs are less than their total monthly waiver obligation may keep the excess income and continue to receive waiver and MA services.

If both spouses are receiving or applying for EW, determine eligibility separately for each spouse. If one spouse is eligible under SIS EW and the other is not, compute a waiver obligation for the SIS EW spouse and a spenddown for the non-SIS EW spouse, using a household size of 1 for each spouse.

EXAMPLE:

Ethel is single. She receives gross RSDI of $700. After deducting her Medicare premium and the maintenance needs allowance, there is no income remaining. She is eligible for SIS EW with no waiver obligation.

EXAMPLE:

Tony is single and has gross income of $1,200. He is covered by Medicare Part A and B. After deducting his Medicare premium of $88.50 and maintenance needs allowance of $816, he has income of $295 remaining. This is his waiver obligation.

EXAMPLE:

Julie and John, a married couple. both receive EW services. Julie has gross RSDI of $880 and John has gross RSDI of $840. Both have Medicare premiums deducted. Determine eligibility for each spouse using a household size of 1 and the individual income. Since both have gross income less than the SIS, both will be eligible for SIS EW. Deduct the Medicare premium and maintenance needs allowance from each spouse’s income to determine the waiver obligation for each.

If one spouse has gross income over the SIS, compute a spenddown for that spouse using Method B budgeting and the appropriate income standard for a household size of 1.

If one spouse is eligible under SIS EW and the other spouse resides in a nursing facility or medical institution, compute separate LTC budgets for each spouse, allowing the personal needs allowance for the LTC spouse and the monthly maintenance needs allowance for the EW spouse. Do not allow spousal allocation.

EXAMPLE:

Mike and Susan are a married couple. Mike resides in a LTCF facility and receives gross RSDI of $1,450. Susan receives EW services and has gross RSDI of $500. Compute an LTC spenddown for Mike allowing the clothing and personal needs allowance. Compute a waiver obligation for Susan using the monthly maintenance allowance. Since Susan’s income is less than the maintenance needs allowance, she has no waiver obligation. She cannot receive a spousal allocation from Mike.

If a person who is eligible under SIS EW has a community spouse, use LTC budgeting with a household size of 1, allowing the maintenance needs allowance for the EW spouse. Allow spousal allocation to the community spouse if requested. If the community spouse applies for MA, use a household size of 1. The community spouse may refuse the allocation if it is to his/her benefit. See COMMUNITY SPOUSE in §0902.07 (Glossary: Client...) for a definition and §0912.05.25.03 (Allocations--Community Spouse) for instructions on computing the allocation amount.

EXAMPLE:

George receives EW services. His gross income of $1,495 is less than the SIS, so he is eligible under the SIS EW. His wife Martha does not receive MA. She receives RSDI of $376. George may allocate income to Martha to bring her up to the basic spousal needs allowance. After deducting his Medicare premium, monthly maintenance needs allowance, and spousal allocation, he has no waiver obligation.

EXAMPLE:

Jack receives EW services. His gross income is less than the SIS, so he is eligible under the SIS EW. His wife, Jill, lives with him and does not receive EW services. She is considered a community spouse. Jill’s income is less than the basic spousal needs allowance. Jill may request a spousal allocation from Jack. If the allocation results in a spenddown she cannot meet, she may refuse the allocation. This will result in a larger waiver obligation for Jack. Help them determine which is more advantageous.

Return to Top

RELATIONSHIP BETWEEN EW AND AC 0913.13.07

MinnesotaCare:

No provisions.

MA:

People cannot receive services through Alternative Care (AC) and the Special Income Standard-Elderly Waiver (SIS-EW) at the same time. People who meet the MA asset limit may be able to choose between AC and EW depending on their income level.

People cannot choose to receive AC if they are:

• Eligible for MA without a spenddown (income equal to or less than 100% FPG).

OR

• Eligible for SIS-EW with gross income at or below 120% FPG). MA applicants with incomes at or below 120% FPG may receive AC for up to 60 days pending the MA eligibility determination.

EXAMPLE:

Marge requests home and community based services beginning in January. She applies for MA on January 15 and requests retroactive coverage for November and December. Her assets are within the MA limit. Her income is less than 120% FPG. AC services can be used to pay for home and community based services for up to 60 days or until MA is approved, whichever is earlier.

People who meet the MA asset limit and who have incomes over 120% FPG but no more than the special income standard (SIS) can choose to receive home and community based services through either SIS-EW or AC. People who choose AC are not eligible for MA with a spenddown.

EXCEPTION:

If people choose AC and later apply for EW, AC may remain open while the MA application is processed. The applicant may use AC expenses to meet a spenddown during the 3-month retroactive period and the processing period. Once SIS-EW is approved, the enrollee will have a waiver obligation. See §0913.17 (Begin/End Use of LTC Spenddown-Part 1).

EXAMPLE:

Bob has been receiving AC services for 12 months. His assets are within MA limits. He applies for SIS-EW on April 5. Based on his income, he has a monthly MA spenddown of $300 and will have a waiver obligation for SIS-EW of $80. He can use expenses paid by AC to meet his spenddown while his SIS-EW eligibility is determined. Once SIS-EW is approved, AC services end. Bob will have a waiver obligation instead of a spenddown beginning with the first full month of SIS-EW services.

EXAMPLE:

Marge is approved for AC services beginning in January. She applies for MA on January 15 and requests retroactive coverage for November and December. Her assets are within the MA limit. Her income is more than the maintenance needs allowance but less than 120% FPG. She has a spenddown for MA and will have a waiver obligation for SIS-EW. She can use AC-paid services to meet her spenddown beginning in January while SIS-EW eligibility is determined. AC services can continue during the MA processing period or until SIS-EW is approved. Since she did not receive AC services in November and December, she must meet her spenddown for those months with other medical expenses.

People with assets within the MA limits and incomes more than the SIS may choose to receive services through either AC or EW. People who choose AC may be eligible for MA with a spenddown, using AC expenses to meet the spenddown. People who choose EW and MA with a spenddown cannot apply expenses paid by EW to the spenddown. They may apply costs incurred under EW that remain their financial responsibility to the spenddown.

EXAMPLE:

Elaine’s assets are within MA limits. Her income is more than the SIS. She would have a monthly MA spenddown of $1,200. She receives monthly AC services of $1,100, reducing her spenddown to $100. She must incur $100 in other medical expenses to meet her spenddown.

Return to Top

COMBINATION LTC/MEDICAL SPENDDOWN 0913.15

MinnesotaCare:

No provisions.

MA:

For information on when to use a combination LTC/Medical spenddown, see §0913.05 (Which Spenddown Type to Use).

Before doing a spenddown calculation for months in which clients enter or leave a facility, are in temporary LTCF placement, or begin or end elderly waiver (EW) services, see §0913.17 (Begin/End Use of LTC Spenddown - Part 1), §0913.17.01 (Begin/End Use of LTC Spenddown - Part 2), and §0913.17.03 (Begin/End Use of LTC Spenddown - Part 3).

People whose eligibility is determined using a combination LTC/Medical spenddown must have their eligibility determined monthly because their cost of care and/or income may fluctuate. Do a manual monthly spenddown calculation each month. See §0905.07 (Monthly Reporting) and §0913.11 (Manual Monthly Spenddown Calculation).

Follow the procedures in the rest of this section for:

• People residing in an LTCF.

AND

• People on the Elderly Waiver (EW) who have community spouses and who are not eligible under the SIS EW, if the spenddown exceeds the cost of EW services. See §0913.13.03 (LTC Spenddown--EW With Community Spouse). Compute a waiver obligation for people with income equal to or less than the Special Income Standard (SIS). See §0913.13.05 (Waiver Obligation--SIS EW).

To calculate the spenddown in a month the client is subject to LTC budgeting, begin with the total gross unearned and countable earned income received by the client in that month. Include all excluded and non-excluded types of income except for income tax refunds, property tax refunds, and earned income tax credits.

Calculate countable earned income as follows:

Count all gross earned income and net self-employment income of an LTCF resident unless the resident is disabled and receiving wages from employment under an individual plan of rehabilitation.

Allow the following deductions in the order listed from gross earned income of disabled people who are receiving wages from employment under an individual plan of rehabilitation:

1. $80 special personal allowance. See §0912.05.09.07 (Special Personal Allowance Disregard).

2. Actual FICA withheld.

3. Actual transportation expenses.

4. Actual employment expenses such as tools and uniforms.

5. State and federal taxes (only when the person is not exempt from withholding).

Allow the following deductions from the total gross unearned and countable earned income in the order listed:

1. Exclusions from income of institutionalized people mandated under federal law. These exclusions include:

• German Reparation payments • Japanese and Aleutian Restitution payments • Agent Orange Settlement Fund payments • Radiation Exposure payments • payments under the Domestic Volunteer Services Act • payments received under the White Earth Land Settlement Act (WELSA) • Netherlands Act (WUV) payments to victims of Nazi persecution • Vietnamese Commando Compensation payments • payments to children of Viet Nam veterans with spina bifida • Austrian reparation payments • Blood Product Settlement Payments • payments by the Secretary of Defense to people captured and interned by North Vietnam.

VA pensions limited to $90 per month are also excluded as the person’s clothing and personal needs allowance. See §0912.07.03 (Clothing and Personal Need Allowance).

If you are unsure whether a particular payment meets this exclusion, submit a policy interpretation. Include the applicable public law number if known.

2. Medicare premiums of clients who are not Qualified Medicare Beneficiaries (QMBs), Service Limited Medicare Beneficiaries (SLMB's), or Qualified Individuals (QI). See §0907.21.09 (MA Basis: Medicare Supplement Programs).

3. Clothing and personal needs allowance. See §0912.07.03 (Clothing and Personal Need Allowance). For single residents in a temporary LTCF placement, allow instead the home maintenance allowance. See §0913.17.01 (Begin/End Use of LTC Spenddown - Part 2).

4. Guardianship fees to a legally appointed guardian or conservator, or representative payee fees to an appointed representative payee authorized by the Social Security Administration. Allow up to 5% of the client's gross monthly income to a maximum of $100 after totaling all guardianship, conservator, and SSA representative payee fees. Apply the 5%/$100 maximum even if SSA or a court allows a greater amount.

5. Allocation to a community spouse. See §0912.05.25.03 (Allocations--Community Spouse).

6. Court-ordered child support garnished from income up to a maximum of $250 per month per client. First apply part or all of the garnished amount as the allocation to the child(ren). See §0912.05.25.05 (Allocations--Other Relatives). Enter the balance up to the $250 limit, in the MAXIS long term care budget guardianship fee field along with any allowable guardianship fee. Apply both current support and arrearages up to the maximum allowed.

7. Allocation to a family member other than a community spouse. See §0912.05.25.05 (Allocations--Other Relatives).

8. Continued community level SSI benefits paid under section 1611(e)(1)(G) of the Social Security Act to people who are expected to be institutionalized for a temporary stay of no more than 3 months and who need to continue to maintain a home, for up to 3 months, as verified by the Social Security Administration.

9. Continued community level SSI benefits paid under section 1611(e)(1)(E) of the Social Security Act to people who were 1619(a) or (b) in the month before the 1st full month of institutionalization, for up to 2 months, as verified by the Social Security Administration.

Subtract the current month's LTCF cost of care or EW services from the amount left after these deductions. The remainder is the monthly medical spenddown amount. LTCF clients are responsible for the monthly LTCF charges and the monthly medical spenddown amount. Follow §0913.11 (Manual Monthly Spenddown Calculation) to determine if the client meets the medical spenddown each month.

Some LTC residents may receive periodic payments which cause income to exceed the LTC spenddown amount only in the months the payment is received. Use a regular LTC spenddown for all other months. If you can reasonably anticipate the receipt and amount of the special payment, set the case up with a combination LTC/medical spenddown for the month in which the payment is expected. Do not close the case. Review assets the month following the month the payment is received. If the amount of the payment remaining after deducting all medical bills for the receipt month causes excess assets, advise the client of the need to reduce assets. Close MA if the client fails to reduce assets to within limits by the end of the month following the month in which the special payment is received.

EXAMPLE:

John resides in a LTC facility and is eligible with a LTC spenddown of $1,300 per month. His regular medical expenses include LTC costs of $3,300, prescriptions totaling $100, and therapy costs of $200. He receives an annual net land rental payment of $3,000 every December. He has countable assets of $2,800. Leave the case open with a combination LTC/medical spenddown of $4,300 for December in case he incurs medical bills in excess of the anticipated amount of $3,600.

Contact John’s authorized representative in January to determine if he incurred additional medical bills of at least $700 (the difference between the $4,300 spenddown and the usual charges of $3,600) in December. If not, determine if he retained $200 or more of the excess, which would result in excess assets. If so, advise the authorized representative that John’s assets must be reduced to $3,000 or less. Send 10-day notice to close MA effective February 1 if assets have not been reduced.

NOTE:

John may reduce the excess in either December or January by any means that does not result in an improper transfer penalty. Do not require verification of each expenditure. Verify that liquid assets are within limits by the end of January.

GAMC:

No provisions.

Return to Top

BEGIN/END USE OF LTC SPENDDOWN - PART 1 0913.17

MinnesotaCare:

No provisions.

MA:

Redetermine eligibility when clients enter or leave a long term care facility (LTCF) or when a person with a community spouse begins or ends receiving elderly waiver services. Require clients to report changes in living situation within 10 days of the date the change occurred. Verify income changes resulting from the change in living situation. Give proper notice when acting on a reported change. See §0916 (Notices).

LTC SPENDDOWN BEGIN DATE: CLIENT WITH NO COMMUNITY SPOUSE ENTERS LTCF

When a client with no community spouse enters an LTCF, begin an LTC spenddown on the first day of the first calendar month after the date the client was admitted to the LTCF. If the client was active on MA with a 6-month spenddown, calculate a shortened spenddown and new satisfaction date for the months in the certification period before the client became subject to an LTC spenddown. If the calculation results in an earlier satisfaction date, notify the client to advise appropriate providers to bill MA. Do not adjust the spenddown if the calculation results in a later satisfaction date or an increase in the recipient amount on the original satisfaction date.

EXAMPLE:

Alfred is residing in the community and is eligible for MA with a 6-month spenddown. His income certification period is May-October. On August 12, Alfred enters a LTCF for a permanent stay.

Redetermine Alfred's eligibility as follows:

1. Recalculate a new spenddown amount and satisfaction date for May-August to determine a new spenddown amount and satisfaction date for a four month period. Notify Alfred if the calculation results in an earlier satisfaction date so that he can notify the appropriate medical providers to bill MA.

2. Calculate an LTC spenddown for September and October. Notify Alfred of the LTC spenddown amount. Timely notice is not required. Begin a new 6-month certification period using an LTC spenddown for November-April.

If the client was active on MA with a monthly spenddown or no spenddown, begin using LTC deductions beginning with the 1st full calendar month of LTCF residence.

LTC SPENDDOWN BEGIN DATE: CLIENT WITH COMMUNITY SPOUSE ENTERS LTCF OR BEGINS RECEIVING EW SERVICES

When a client with a community spouse enters an LTCF or begins receiving EW services, begin an LTC spenddown on the 1st day of the month in which the client was admitted to the LTCF or began receiving EW services. When determining the LTC spenddown amount, use the clothing and personal needs allowance for the LTC spouse. See §0912.07.03 (Clothing and Personal Need Allowance). Use a household size of 1 for the community spouse for the month of institutionalization. The community spouse may also receive an allocation. If the community spouse also receives MA, he/she may elect not to receive an allocation if the allocation amount increases the MA spenddown. See §0912.05.25.03 (Allocations--Community Spouse).

If the couple was active on MA with a 6-month spenddown, calculate a new spenddown and satisfaction date for the LTC or EW spouse for the months in the certification period before the LTC spenddown began. Recalculate the spenddown for the community spouse for the entire certification period. Use both spouse’s income for the months before the LTC spenddown began. Use only the community spouse’s income for the remaining months in the certification period. Use a household size of 2 for the community spouse for the months before institutionalization. Use a household size of 1 for the remainder of the certification period. If either calculation results in an earlier satisfaction date, notify the couple to advise appropriate providers to bill MA. Do not adjust the spenddown if the calculation results in a later satisfaction date.

EXAMPLE:

Alma is residing in the community with her husband Allen. They were receiving MA with a 6-month spenddown and income certification period of November-April. On February 1, Alma becomes eligible for EW.

Redetermine Alma and Allen's eligibility as follows:

For Alma:

1. Calculate a new spenddown amount and satisfaction date for November-January, using a household size of 2 and both Alma's and Allen's incomes. Notify the couple if the calculation results in an earlier satisfaction date so they can notify the appropriate medical providers to bill MA. 2. Calculate an LTC spenddown for February-April, using Alma's income and a household size of 1.

For Allen:

Calculate a new spenddown amount and satisfaction date for the entire 6-month spenddown period. Use a household size of 2 for November-January and a household size of 1 for February-April. Use Allen’s income for the entire period and Alma’s income for November-January. Notify the couple if the calculation results in an earlier satisfaction date so they can notify the appropriate medical providers to bill MA.

If the couple was active on MA with a monthly spenddown or no spenddown, begin using LTC deductions beginning with the month the LTC spouse entered the LTCF or began receiving EW services. Recalculate the community spouses's spenddown amount using a household size of 1 and only the community spouse's income for the months of LTC spenddown.

For clients eligible under the SIS EW program, see §0913.17.05 (Begin/End Use of SIS EW Waiver Obligation).

Continued in §0913.17.01 (Begin/End Use of LTC Spenddown - Part 2) and §0913.17.03 (Begin/End Use of LTC Spenddown - Part 3).

Return to Top

BEGIN/END USE OF LTC SPENDDOWN - PART 2 0913.17.01

MinnesotaCare:

No provisions.

MA:

The following is continued from §0913.17 (Begin/Use of LTC Spenddown - Part 1).

LTC SPENDDOWN: CLIENT ENTERS AND LEAVES LTC DURING A CERTIFICATION PERIOD

Clients without community spouses are entitled to a home maintenance allowance if they are residing in a temporary LTCF placement and they meet all 3 conditions below. The home maintenance allowance is the income standard that would be used for a household size of 1 in the community for eligibility under Method B without a spenddown. See §0912.07.100 (100% of FPG). Allow the home maintenance allowance instead of the clothing and personal needs allowance for up to 3 months if:

1. A physician certifies the client will be in the LTCF for 3 months or less and will return to independent living upon discharge from the LTCF.

2. The client has expenses of maintaining a residence in the community.

3. At the time of entering the LTCF the client was not living with:

• Children under 21. • Children over 21 claimed as a tax dependent. • Parents claimed as dependents. • Siblings claimed as dependents. • A spouse. However, if the client and spouse were institutionalized on the same date and both are expected to remain for at least one calendar month, use an LTC spenddown. If one or both spouses is expected to return to the community in 3 months or less and there are expenses for maintaining a home in the community, use the clothing and personal needs standard for one spouse and the 100% of FPG standard (household size of 1) for the other spouse.

Take the following steps if a client without a community spouse who was active on MA with a 6-month spenddown enters temporary LTCF placement:

1. Recalculate a medical spenddown for the months before the beginning of the LTC spenddown using a shortened spenddown period.

2. Calculate an LTC spenddown for the months the client received LTC services. When a client has a community spouse, the LTC spenddown must be calculated beginning with the month LTC services began. If the client has no community spouse, begin the LTC spenddown with the first full calendar month of LTCF residence.

3. Calculate a monthly medical spenddown period for the remaining months after the LTC spenddown ends. Use either an automated or a manual monthly spenddown depending on whether income fluctuates. See §0913.05 (Which Spenddown Type to Use).

EXAMPLE:

Martha resides alone in the community and is eligible for MA with a 6-month spenddown. Her income certification period is September-February. On November 5, Martha is unexpectedly admitted to a LTCF for a temporary stay to recover from surgery. Martha returns to her home on January 3.

Redetermine Martha's eligibility as follows:

1. Calculate a new spenddown amount and satisfaction date for September-November. Notify Martha if the calculation results in an earlier satisfaction date so that she can notify the appropriate medical providers to bill MA.

2. Calculate an LTC spenddown for December. Allow the home maintenance allowance rather than the personal needs allowance. Notify Martha of the LTC spenddown amount.

3. Calculate a monthly medical spenddown for January and February. Begin a new 6-month certification period in April.

LTC SPENDDOWN BEGIN DATE: CLIENT WITH NON-MA COMMUNITY SPOUSE BEGINS AND ENDS EW SERVICES

When a client with a 6-month spenddown and a community spouse who is not active on MA begins and ends EW during a certification period, take the following steps:

1. Recalculate a medical spenddown for the months before the beginning of the LTC spenddown using a shortened spenddown period.

2. Calculate an LTC spenddown for the months the client received LTC services. When a client has a community spouse, the LTC spenddown must be calculated beginning with the month LTC services began.

3. Calculate a 1-month medical spenddown period for the remaining months after the LTC spenddown ends.

EXAMPLE:

Gerry resides in the community with her husband, Sam, and is eligible for MA with a 6-month spenddown. Sam does not receive MA. Gerry's income certification period is June-November. On August 1, Gerry becomes eligible for EW. Eligibility for EW ends on October 31 when she is no longer at risk of LTC placement.

Redetermine Gerry's eligibility as follows:

1. Calculate a new spenddown amount and satisfaction date for June and July. Notify Gerry if the calculation results in an earlier satisfaction date so that she can notify the appropriate medical providers to bill MA.

2. Calculate an LTC spenddown for August, September, and October. Notify Gerry of the LTC spenddown for each month.

3. Calculate a monthly medical spenddown for November. Begin a new income certification period in December.

For clients eligible under the SIS EW program, see §0913.17.05 (Begin/End Use of SIS EW Waiver Obligation).

Continued in §0913.17.03 (Begin/Use of LTC Spenddown - Part 3).

GAMC:

No provisions.

Return to Top

BEGIN/END USE OF LTC SPENDDOWN - PART 3 0913.17.03

MinnesotaCare:

No provisions.

MA:

The following is continued from §0913.17 (Begin/Use of LTC Spenddown - Part 1) and §0913.17.01 (Begin/Use of LTC Spenddown - Part 2).

LTC SPENDDOWN BEGIN DATE: APPLICANT ENTERS PERMANENT LTC PLACEMENT

When an applicant who enters permanent LTC placement requests retroactive MA for the months before the LTC spenddown begins, use either a 6-month certification period with a shortened spenddown or a 1-month medical spenddown to determine eligibility for the months before placement. See §0913.11 (Manual Monthly Spenddown Calculation), §0913.09 (Automated Monthly Spenddown Calculation), and §0913.07 (6-Month Spenddown Calculation). Begin using an LTC spenddown starting the first month the client is required to use an LTC spenddown. For a client with no community spouse, the LTC spenddown begins the month following the month of LTC placement. For a client with a community spouse, the LTC spenddown begins the month of placement. See §0913.05 (Which Spenddown Type to Use), §0913.13 (Long Term Care Spenddown Calculation), and §0913.15 (Combination LTC/Medical Spenddown).

For a 6-month spenddown, use the community assistance standard for any months before the month the LTC spenddown begins. Use the income deductions for long term care spenddowns in §0913.13 (Long Term Care Spenddown Calculation) beginning with the month the client becomes subject to an LTC spenddown.

Apply excess income in the months before LTCF placement toward medical expenses incurred in those months. Start with the oldest expense.

EXAMPLE:

Catherine applies for MA on April 25. She entered an LTCF for a permanent stay on April 10. She has no community spouse. She is requesting retroactive MA for February and March. She was hospitalized for 2 weeks in February and again from March 25 until she entered the LTCF. Use either a shortened 6-month spenddown or a monthly spenddown for February and March. Begin the LTC spenddown in April. April is considered the first full month of institutionalization since Catherine entered the LTCF directly from the hospital.

LTC SPENDDOWN END DATE: CLIENT WITH NO COMMUNITY SPOUSE LEAVES LTC

When a client with no community spouse leaves LTC placement, end the LTC spenddown for the end of the month prior to the month of discharge. Redetermine eligibility for the remainder of the certification period using a monthly spenddown. If the client cannot meet the spenddown, terminate MA for the first month for which you can give 10-day notice.

EXAMPLE:

Bertha has resided in an LTC for 9 months. Her current income certification period is June-November. She has no community spouse. She is discharged from the LTC to her home on August 9. Redetermine eligibility for August-November using a monthly medical spenddown. Terminate MA if Bertha cannot meet the spenddown.

LTC SPENDDOWN END DATE: CLIENT WITH COMMUNITY SPOUSE LEAVES LTCF OR ENDS EW SERVICES

When a client with a community spouse leaves LTC placement or stops receiving EW services, continue the LTC spenddown through the end of the month of discharge or end of EW services. Redetermine eligibility using a monthly medical spenddown for the remainder of the certification period. Terminate MA for the first month for which you can give 10-day notice if the client cannot meet a spenddown.

EXAMPLE:

Tobias has received EW services for 8 months. He lives with his wife Rachel, who is not receiving MA. Tobias's current income certification period is February-July. EW services end effective May 31, because he is no longer at risk of placement. Redetermine eligibility for June and July using a monthly spenddown. Terminate MA if Tobias cannot meet the spenddown.

Continue to use LTC budgeting through the month of discharge when the discharge is due to death.

For clients eligible under the SIS EW program, see §0913.17.05 (Begin/End Use of SIS EW Waiver Obligation).

GAMC:

No provisions.

Return to Top

BEGIN/END USE OF SIS EW WAIVER OBLIGATION 0913.17.05

MinnesotaCare:

No provisions.

MA:

Redetermine eligibility when a person begins or ends eligibility under the SIS EW program. See §0913.13.05 (Waiver Obligation--SIS EW).

SIS EW BEGIN DATE: CLIENT WITH NO COMMUNITY SPOUSE BEGINS EW

When a client with no community spouse becomes eligible under the SIS EW program, begin the waiver obligation on the first day of the first calendar month after the client is approved for EW services.

EXAMPLE:

Theodore lives in the community and receives Alternative Care (AC) services. On September 15, his case manager determines he is eligible for EW. He applies for MA on September 20 and is approved on October 10, retroactive to September 1. He is eligible for SIS EW because his income is less than the Special Income Standard (SIS).

Begin Theodore’s waiver obligation on October 1, the first calendar month after his case manager determined he was eligible for EW. Use a manual monthly spenddown for September.

SIS EW BEGIN DATE: CLIENT WITH COMMUNITY SPOUSE BEGINS EW

When a client with a community spouse begins EW, begin the waiver obligation with the month in which the client began receiving EW services.

EXAMPLE:

Rita lives in the community with her husband, Ralph. Rita receives AC services. On July 18, her case manager determines she is eligible for EW. She applies for MA and is approved on August 20. She is eligible for SIS EW because her income is less than the SIS.

Begin Rita’s waiver obligation effective July 1, the month in which she began receiving EW services.

SIS EW END DATE: ENROLLEE WITH NO COMMUNITY SPOUSE ENDS EW

When an enrollee with no community spouse ends eligibility under SIS EW, redetermine eligibility for the 6-month certification period using a monthly spenddown, starting with the month in which EW eligibility ends. If the enrollee cannot meet the spenddown, terminate MA for the first month for which you can give 10-day notice.

EXAMPLE:

Bertha has been receiving EW services for 9 months. She has a waiver obligation under SIS EW. Her current certification period is June-November. On August 9, her case manager determines she is no longer eligible for EW. Redetermine eligibility for August-November using a monthly spenddown. Terminate MA if Bertha cannot meet the spenddown. Give 10-day notice for termination or increased spenddown.

SIS EW END DATE: ENROLLEE WITH COMMUNITY SPOUSE ENDS EW

When an SIS EW enrollee with a community spouse stops receiving EW services, continue the waiver obligation through the last month in which the enrollee receives EW. Redetermine eligibility for the remainder of the certification period using a monthly medical spenddown. Terminate MA for the first month for which you can give 10-day notice if the enrollee cannot meet the spenddown.

EXAMPLE:

Tobias has received services under SIS EW for 8 months. He lives with his wife, Rachel, who does not receive MA. His current income certification period is February-July. EW services end May 31 because Tobias is no longer at risk of nursing facility placement. Redetermine eligibility for June and July using a monthly spenddown with a household size of 2 and both spouses’ incomes. Terminate MA if Tobias cannot meet the spenddown.

For clients with community spouses who are not eligible under SIS EW, see:

§0913.17 (Begin/End Use of LTC Spenddown - Part 1)

§0913.17.01 (Begin/End Use of LTC Spenddown - Part 2)

§0913.17.03 (Begin/End Use of LTC Spenddown - Part 3)

Return to Top

SHORTENED SPENDDOWN 0913.19

MinnesotaCare:

No provisions.

MA:

Use a shortened income certification period when:

• An income certification period with a 6-month spenddown is closed due to the client's enrollment in MinnesotaCare. Inform the client that spenddown eligibility exists for the full 6-month income certification period with the satisfaction of the existing spenddown. If the client opts to change to MinnesotaCare, calculate a shortened spenddown for the months before MinnesotaCare begins.

• Eligibility is terminated during an income certification period with a 6-month spenddown. Calculate a new spenddown and satisfaction date for the months before termination. Notify the household if the calculation results in an earlier satisfaction date. Do not adjust the spenddown if the calculation results in a later satisfaction date or an increased recipient amount on the original date of satisfaction.

EXAMPLE:

Delbert and Norma receive MA with a 6-month spenddown. Their income certification period is February-July. They report they moved out of state on April 6. Terminate MA effective May 1. Calculate a new spenddown amount and satisfaction date for February-April. Notify the household if the calculation results in an earlier satisfaction date so they can notify appropriate providers to bill MA.

• An income certification period with a 6-month spenddown is interrupted. See §0913.19.03 (When to Interrupt 6-Month Cert. Period) and §0913.19.05 (When Not to Interrupt 6-Month Cert. Period).

GAMC:

No provisions.

Return to Top

WHEN TO INTERRUPT 6-MONTH CERT. PERIOD 0913.19.03

MinnesotaCare:

No provisions.

MA/GAMC:

Also see §0913.19 (Shortened Spenddown) and §0913.19.05 (When Not to Interrupt 6-Month Cert. Period).

Interrupt a 6-month income certification period and begin a new 6-month income certification period:

• When a previously scheduled cash, MA, or Food Stamp annual recertification is due during a current income certification period. Complete the recertification and begin a new income certification period with the recertification month.

EXAMPLE:

William and Patsy and their three children are receiving Food Stamps and MA. They were approved for Food Stamps effective June 13. They applied for MA the following March and were approved effective March 3 with a 6-month spenddown. The Food Stamp recertification is scheduled for June. The MA income certification period is March-August.

Redetermine eligibility for both Food Stamps and MA for June. Interrupt the existing MA certification period and begin a new income certification period for June-November. The next Food Stamp and MA annual recertification will be due at the same time in the following June.

Calculate a new spenddown amount and satisfaction date for March, April, and May using actual income for those months. Apply the same bills as were used to calculate the original spenddown. Notify William and Patsy if the calculation results in an earlier satisfaction date, or a decreased recipient amount on the original satisfaction date, so they can notify appropriate providers to bill MA. Do not adjust the spenddown if the calculation results in a later satisfaction date or increased recipient amount on the original satisfaction date.

• When a MinnesotaCare renewal is due during an existing MA or GAMC certification period for other household members. Do not adjust the MA or GAMC certification period if some or all household members receive cash or Food Stamps with a different recertification date. Align the MA or GAMC certification period with the cash or Food Stamps recertification. Do not adjust a MinnesotaCare renewal date to align with any other programs.

EXAMPLE:

Leo and Prudence apply for MA and Food Stamps for themselves and their two children. Both programs are approved effective July 1. Leo and Prudence apply for MinnesotaCare for themselves the following March and are approved as pending awaiting payment in April. Their MA is terminated effective April 1. The children remain on MA and the entire household remains on Food Stamps. The MA and Food Stamp recertifications will be due in July. The MinnesotaCare renewal will be due in April. Do not adjust the MA certification period to align with the MinnesotaCare renewal.

EXAMPLE:

Larry and Liz apply for MA for themselves and their three children. MA is approved for the entire household effective April 1. No one in the household is open on cash or Food Stamps. MA is terminated for Larry and Liz effective October 1 because they can no longer meet a spenddown. The children remain on MA without a spenddown. Larry and Liz apply for MinnesotaCare for themselves in November and are approved as pending awaiting payment in December.

Interrupt the children’s existing October-March MA certification period and begin a new certification period for December-May. If the children remain eligible for MA at the time of the 6-month income review, the MA and MinnesotaCare renewals will be due at the same time the following December.

• When adding a person, except a newborn, who increases the household size. Do not interrupt the certification period or recalculate the spenddown when adding a newborn who was already included in the household size as an unborn. The newborn is eligible without a spenddown through the month of the 2nd birthday if the conditions in §0907.19.05.03 (MA Basis: Auto Newborn) are met.

For all others, end the current 6-month income certification period for the existing household on the last day of the month before the month the new member is added. See §0915.03.01 (Adding a Person to the Household--MA/GAMC) and §0908.05 (Determining MA/GAMC Household Size).

When the existing household has a 6-month spenddown, compute a shortened spenddown for the existing household when the certification period is interrupted. Also compute a shortened spenddown for the new member using a household size of 1. For the new member, the shortened spenddown runs from the first retroactive month requested through the month before the month the new member is added to the existing household. This will include the month the new member enters the household if he/she enters after the 1st of the month.

For additional information, see TEMP Manual TE02.07.229 (Adding People to the MA/GAMC Household).

EXAMPLE:

Rita applies for MA for herself and her 3 children in June. They are found eligible without a spenddown effective July 1. Rita's husband, Ron, returns home on September 15 and completes an addendum to be added to MA October 3. Interrupt the income certification period for Rita and the children and begin a new income certification period beginning in October. Use both Rita's and Ron's incomes and a household size of 5.

If Ron requests MA retroactive to July, determine his eligibility for July, August, and September using a shortened certification period. Use only Ron’s income and a household size of 1. Ron may choose to use either a monthly spenddown or a shortened 6-month spenddown if he has a basis of eligibility for MA. If he has no MA basis and is eligible for GAMC, he is not eligible for retroactive coverage.

• When a person who was included in the existing household size but did not request MA now requests MA for a period BEFORE the household's current income certification period. The new income certification period will begin on the first day of the earliest requested retroactive month for all household members. The added member is subject to the spenddown type selected by the household at the time the last certification period was approved. Redetermine the entire household's eligibility using an income certification period starting with the new member's earliest eligible retroactive month.

EXAMPLE:

Mike applied for MA for his two children in April. He did not request MA for himself because he had other coverage. The children were found eligible with no spenddown and an income certification period of April-September.

On June 5, Mike requests MA for himself retroactive to March for some bills not covered by his other insurance. Determine eligibility for Mike and his children as follows:

1. Redetermine eligibility using an income certification period for the entire household of March-August based on actual and anticipated income for those months. If Mike has a spenddown, he may choose either a 6-month or a 1-month spenddown because he has a basis of eligibility for MA and the children had no spenddown for any month in the original certification period. See §0913.05 (Which Spenddown Type to Use). Use Mike's bills and any bills the children incurred before becoming eligible for MA to meet the spenddown.

2. If Mike is eligible without a spenddown or can satisfy the spenddown for the new period, end the children's existing income certification period effective July 1 and include them with Mike in the new certification period.

• When a client's automatic MA eligibility ends, such as infants, MSA, IV-E, or 60-day postpartum unless the woman meets the requirements to eliminate the postpartum review. In that case, do not interrupt the budget period. See §0905 (Reviews and Renewals). • When a client in a single person household dies, end the current income certification period on the last day of the month in which the death occurred. Recalculate the spenddown and satisfaction date using the shortened spenddown period.

EXAMPLE:

Roger receives MA with a 6-month spenddown and an income certification period of May-October. Roger died on September 12. Terminate MA on the date of death.

Recalculate Roger's eligibility for a 5-month period using his income from May 1 through September 12. If the calculation results in an earlier satisfaction date, notify Roger's representative so that appropriate providers can bill MA.

Return to Top

WHEN NOT TO INTERRUPT 6-MONTH CERT. PERIOD 0913.19.05

MinnesotaCare:

No provisions.

MA:

Also see §0913.19 (Shortened Spenddown) and §0913.19.03 (When to Interrupt 6-Month Cert. Period).

Do not interrupt an income certification period:

• When an MA-only person becomes eligible for automatic MA with cash assistance (MSA, GRH). The income certification period will include MA-only months and automatic months. Recompute the spenddown for the MA-only months using the applicable MA standard and income. See §0912.07 (Income Standards). For the cash eligibility months, enter the appropriate cash ELIG type and standard on MAXIS.

EXAMPLE:

Patrick receives MA as a disabled person with a 6-month spenddown and an income certification period of April-September. He became eligible for MSA and automatic MA on June 1.

Calculate a new spenddown amount and satisfaction date for March, April, and May using actual income for those months. Apply the same bills as were used to calculate the original spenddown. Notify William and Patsy if the calculation results in an earlier satisfaction date so they can notify appropriate providers who provided services between the old and new satisfaction dates to bill or rebill MA. If the recalculation results in a lower recipient amount on the original satisfaction date, claims will be reprocessed automatically. Do not adjust the spenddown if the calculation results in a later satisfaction date or increased recipient amount on the original satisfaction date.

When applicants for a type of cash assistance that includes automatic MA also request retroactive MA, begin the certification period with the retroactive month in which eligibility began. The initial income certification period will include MA-only months and automatic months. For the MA-only months in the retroactive period, use the applicable MA standard and income based on the household composition during the retroactive period. See §0912.07 (Income Standards). For the cash eligibility months, enter the appropriate cash eligibility type and standard on MAXIS.

EXAMPLE:

Patrick applies for MSA on July 10. He requests retroactive MA for May and June. He is found eligible for MSA effective July 10 with automatic MA effective July 1.

To determine retroactive MA for May and June, use actual income and the MA income standard for those two months. If income exceeds the standard, Patrick may choose to either meet the spenddown on a monthly basis for those months or to meet the combined 2-month spenddown amount (shortened 6-month spenddown).

For the cash assistance months of the certification period (July-October), enter countable income of $0 and the appropriate MSA eligibility type for the remaining months in the certification period.

• When a client enters or leaves an LTCF. See §0913.17 (Begin/End Use of LTC Spenddown - Part 1), §0913.17.01 (Begin/End Use of LTC Spenddown - Part 2), and §0913.17.03 (Begin/End Use of LTC Spenddown - Part 3). • When QMB, SLMB or QI eligibility is added to MA. Do not change the certification period or recalculate the spenddown when someone who is active on MA becomes eligible for QMB, SLMB or QI during the certification period. Begin QMB, SLMB or QI in the first eligible month. • When a household size decreases because a person dies or leaves a current MA household. Recalculate the current 6-month income certification period.

EXAMPLE:

Luke and Laura and their two children are active on MA. Luke and Laura have an automated monthly spenddown and the children have no spenddown. Their current income certification period is March-August. Luke leaves the home on June 4.

Recalculate Laura and the children's eligibility for July (the month after Luke left the home) and August. Decrease the household size to 3 and drop Luke's income. Change the spenddown for Laura effective July 1. If the new calculation results in a spenddown for the children, they must use the same spenddown type as Laura for the remainder of the certification period.

• When a client's income changes. Redetermine eligibility for the current 6-month certification period. • When a person who was included in the existing household size but did not request MA or GAMC now requests MA within the same income certification period. The added member is subject to the spenddown type selected by the household at the time the last certification period was approved. The added member may request to be added up to 3 months before the month they make the request for MA.

EXAMPLE:

Theresa and David applied for MA for their two children on July 8. They did not request coverage for themselves. The children were approved with no spenddown effective July 1 with a certification period of July-December. In September, Theresa requests MA for herself and David because of bills they incurred starting in late July.

Determine eligibility for Theresa and David using the original certification period. If they have a spenddown under the income standard that applies to them, they may have a later opening date than the children.

• When a client’s eligibility changes from MA-EPD to regular MA, resulting in a lower income standard. Redetermine eligibility for the remaining months of the certification period using a monthly spenddown.

EXAMPLE:

Mark is enrolled in MA-EPD with a certification period of September-February. He stops working for non-medical reasons and receives his last pay check in December. He continues to receive RSDI in excess of the income standard for regular MA. Use a monthly spenddown for January and February.

• When people on regular MA become eligible for TMA or TYMA. • When people on TMA or TYMA become eligible for regular MA.

• When people on GHO become eligible for full GAMC for the same time period.

GAMC:

Do not interrupt the certification period when:

People on GHO become eligible for full GAMC for the same time period.

A person who was included in the existing household size but did not request GAMC now requests GAMC within the same income certification period. The new member can be added effective the date of the request.

A GAMC-only enrollee becomes eligible for GA during the income certification period. Since GAMC no longer has spenddown provisions, do not recompute eligibility for the period before GA began. Continue to compare income for the entire 6-month budget period to the 6-month standard.

EXAMPLE:

Roy becomes temporarily unable to work in February and applies for GAMC in February. He receives his last income from employment in February and begins receiving GA in March. His projected return to work date is unknown. His February earnings exceed the monthly GAMC standard, but projected income for the 6-month budget period (0 income projected for March-July) is less than the 6-month standard. He is eligible for GAMC in February as well as for the ongoing GA months.

Return to Top

ALLOWABLE MEDICAL BILLS TO MEET SPENDDOWN 0913.21

MinnesotaCare:

No provisions.

MA:

Use health care expenses in the order listed below to meet medical spenddowns. See §0913.13 (Long Term Care Spenddown Calculation) for expenses used to meet a long term care spenddown. Use medical expenses incurred by clients, their legal dependents, or financially responsible relatives who live with them. Legal dependents and responsible relatives DO NOT have to be applying for or eligible for MA for the client to use their medical expenses.

Use the actual amount billed for the service rather than what MA will pay. The client must verify health care expenses.

Deduct expenses in the following order:

1. Deduct Medicare and health insurance premiums, including MinnesotaCare premiums (or in some cases the MinnesotaCare capitation payment if higher than the premium) and MA-EPD premiums, for any member of the household if the premiums are paid by the client or a financially responsible relative living with the client and will not be reimbursed by MA, QMB, SLMB, QI, or otherwise paid through the Buy-In or reimbursed as cost-effective. See §0910.05.05 (Medicare Premium Payment), §0910.05.03 (Health Insurance Premium Payment) and §0913.21.05 (MinnesotaCare Expenses to Meet Spenddown).

If the client has enough medical expenses other than health insurance and Medicare premiums to meet the spenddown, the client may choose to be reimbursed for cost effective premiums rather than applying them to the spenddown. If the client chooses to apply them to the spenddown, they will be deducted first.

When calculating a 1-month spenddown, deduct the insurance premium on the first day of the month in which the premium is due. If the client is expected to pay Medicare premiums each month, allow the Medicare premium as an automated monthly spenddown expense. On MAXIS, enter the Medicare premium for each month of the certification period on the MA Bill Entry (MABI) panel. Allow health insurance premiums as automated monthly spenddown expenses if you verify that they are paid monthly. Verify the payment at the 6-month income review and at the annual recertification. See §0913.09 (Automated Monthly Spenddown Calculation).

When calculating a 6-month spenddown, deduct Medicare premiums and all other health insurance premiums for any member of the household which were due during the month of application and any of the three retroactive months on the first day of the first retroactive month for which the client is requesting MA or GAMC. Do not deduct Medicare or health insurance premiums paid after the month of application as an expense for 6-month spenddowns. Only use indemnity policy premiums to meet spenddowns if the policy benefits are limited to medical payments for medical expenses. Insurance premiums used to meet medical spenddowns do not have to be cost effective.

Also deduct the $1,000 inpatient hospital copay incurred by household members who were enrolled in GHO on the first day of the MA household member’s 1-month or 6-month spenddown.

2. On the first day of the 6-month or 1-month spenddown period, deduct the unpaid balance of medical expenses incurred prior to the income certification period that the client is obligated to pay. The medical expense may be an expense charged directly to the person by a medical provider, an expense which a medical provider has transferred for collection to a person or agency actively pursuing the collection, or a loan payment owed to a person, financial institution, or credit company for which the loan proceeds were specifically paid to a medical provider.

These expenses must have:

• Been incurred by the client, the client's dependent if the dependent is included in the client's household size or would have been included in the household size if the client had applied when the bill was incurred, the client's siblings, half-siblings, and step-siblings who are included in the client's household size, or the client's spouse or parent (including stepparent) if the spouse or parent's income is actually used to determine eligibility. See §0908.05 (Determining MA/GAMC Household Size).

AND

• Been incurred before the current income certification period.

AND

• NOT been used to calculate a spenddown during a prior income certification period, whether or not the calculation resulted in the spenddown being met, unless eligibility for the entire income certification period was denied.

AND

• NOT been MA/GAMC covered services incurred in a prior period of MA/GAMC eligibility.

3. Deduct the following expenses on the first day of the 6-month or 1-month spenddown period.

• Non-reimbursable expenses incurred during the income certification period not covered by MA/GAMC, such as MA/GAMC co-payments, or reimbursable under the MA Administrative Fund which were NOT reimbursed or paid from the fund, such as transportation. See COVERED SERVICES and TRANSPORTATION COVERAGE in the Minnesota Health Care Programs Provider Manual for information on expenses eligible for reimbursement. See NON-REIMBURSABLE EXPENSES in §0902.27 (Glossary: Non-Citizen...) and MEDICALLY NECESSARY in §0902.23 (Glossary: Managed Care...) for more information on which expenses can be allowed as spenddown deductibles.

For ongoing non-reimbursable expenses, verify the need for the item at each annual review unless the doctor’s recommendation specifies a shorter period.

• Expenses other than health insurance incurred during the income certification period by dependents or financially responsible relatives who are not requesting or on MA/GAMC. Include both reimbursable expenses (which can be paid through MMIS) and non-reimbursable expenses (which are not covered by MA/GAMC or cannot be paid through MMIS), such as co-payments. Include bills paid by MinnesotaCare for family members for whom DHS does not receive FFP. See §0913.21.05 (MinnesotaCare Expenses to Meet Spenddown) for instructions on which MinnesotaCare expenses are allowable. • The following medical expenses incurred by the client or financially responsible relatives:
• Allowable medical care costs for clients in GRH settings.

To determine the amount of remedial care expenses to allow toward the spenddown for GRH residents who are not eligible for the GRH cash program:

1. Subtract the current clothing and personal needs allowance in §0912.07.03 from the 75% of FPG standard for 1 in §0912.07.075. This is the MA room and board rate.

2. Subtract the result from step 1 from the GRH negotiated rate. This is the remedial care amount.

3. Apply the amount from step 2 to the spenddown.

• Alternative Care (AC) (MAXIS service code 30). See §0913.21.03 (Determine Net Medical Expense) and §0913.13.07 (Relationship Between AC and SIS-EW) for information on when AC expenses can be applied to the spenddown. • Minnesota Children Special Health Needs (MCSHN) (MAXIS service code 31). • Insurance Extension Program.

4. Deduct, on the first day of the 1-month spenddown, hospital bills paid by MinnesotaCare for MinnesotaCare recipients who are applying for MA to pay the hospital bill. See §0913.21.07 (MinnesotaCare Inpatient Hospitalization) for specific instructions on MinnesotaCare enrollees who apply for MA to help with hospital costs.

MinnesotaCare enrollees are not eligible for GAMC to help pay hospital costs incurred while they were active on MinnesotaCare.

5. Deduct MA covered services incurred by the client during the 6-month or 1-month income certification period in chronological order by date of service. Include waivered services received through the CAC, CADI, EW, and MR waivers, the net amount of the MSHO spenddown, and Targeted Case Management expenses. Also include prescription costs paid by the Prescription Drug Program (PDP) and PDP deductibles. MMIS will apply the client’s out-of-pocket prescription costs to both the PDP deductible and the spenddown until the spenddown is met. Once the spenddown is met for a given month, the deductible no longer applies.

Although MA and GAMC may limit how often they will pay for some services, and require prior authorization limits for others, do not apply these limits when determining what expenses are acceptable to meet a spenddown.

GAMC:

No provisions.

Return to Top

DETERMINE NET MEDICAL EXPENSES 0913.21.03

MinnesotaCare:

No provisions.

MA:

Use net medical expenses to meet a spenddown. See §0913.21 (Allowable Medical Bills to Meet Spenddown). To determine net medical expenses:

1. Determine if 3rd party coverage exists for each gross medical expense incurred. For spenddown purposes, 3rd party means any person or entity other than the client.

2. Verify the amount of 3rd party payments on expenses. Also verify any denials of payment. The client must provide the verifications necessary to determine liable 3rd party payments.

3. With the exceptions below, subtract 3rd party payments from a gross medical expense to determine the client's net responsibility.

Count payments by these 3rd party programs toward meeting a spenddown:

• MinnesotaCare, except bills paid on behalf of MinnesotaCare enrollees for whom DHS receives FFP. See §0913.21.05. (MinnesotaCare Expenses to Meet Spenddown), for instructions on which MinnesotaCare expenses to allow. • Alternative Care Program (AC) for:

-SIS-EW applicants while MA eligibility is determined

-MA enrollees whose income is over the limits for SIS-EW. See §0913.13.07 (Relationship Between AC and SIS-EW).

• Minnesota Children's Special Health Needs (MCSHN) • Insurance Extension Program.

Do not delay processing an application beyond the standards in §0904.07.03 (Date of Application) if verification of 3rd party payments or intent to pay is still not available. Do not delay redetermining eligibility beyond the due date for other verifications if 3rd party payment verifications or intent to pay is still not available. When verification is not available, estimate 3rd party payments using coverage information in the insurance policy or other sources. Document in the case file how 3rd party payments were determined.

Sometimes liable 3rd parties will issue one payment for several different medical services and not break down the payment by date, type, and cost of each service covered. Try to get a breakdown by date and amount paid on each service from the 3rd party or by examining available coverage information. If this is not possible within the case processing standards (see §0904.07.03, Date of Application), apply the total payment against the services it covers starting with the oldest expense. Continue applying the payment until it is used up. Consider any remaining medical expenses to be the client's responsibility. Use them to meet the spenddown. Document in the case file attempts to get 3rd party information and how 3rd party payments were applied.

Sometimes non-liable 3rd parties, such as a non-responsible relative, pay a client's medical expenses, or vendors write off all or part of a bill. If this happens before the application is processed, deduct the write-off or payment from gross medical expenses. Do not try to anticipate payments from non-liable 3rd parties when determining net medical expenses. Payments made after the county agency approves eligibility have no effect.

GAMC:

No provisions.

Return to Top

MINNESOTACARE EXPENSES TO MEET SPENDDOWN 0913.21.05

MinnesotaCare:

No provisions.

MA:

Some MinnesotaCare expenses may be used to meet a spenddown for household members who receive MA . Expenses paid by MinnesotaCare for which DHS receives or may receive federal financial participation (FFP) cannot be used to meet an MA spenddown. Generally, DHS may receive FFP for MinnesotaCare expenses paid on behalf of the following groups:

• Pregnant women • Children under 21 • Parents and relative caretakers in families with household incomes equal to or less than 275% FPG.

To be eligible for FFP, people must be citizens or meet the MA definition of qualified non-citizens. See §0906.03.03 (Qualified Non-Citizens).

Take the following steps when an MA applicant or enrollee is part of a household that includes MinnesotaCare enrollees:

1. Determine which household members are active on MinnesotaCare. Check the MMIS RELG screen for each household member. Check the coverage dates for these individuals to determine if any MinnesotaCare bills can be used to meet a spenddown.

2. Determine whether each member has a $10,000 inpatient hospital cap and whether DHS is receiving FFP for that member's health care coverage according to the major program. See §0906.03.13 (MMIS Major Programs).

3. Determine if the MinnesotaCare household members are enrolled in a health plan through MinnesotaCare by checking the MMIS RPPH screen. In some cases the capitation payment paid by the state to the health plan can be used to reduce a spenddown. County staff with appropriate security may verify the capitation payment by viewing the claims subsystem.

4. Verify the amount of the monthly MinnesotaCare premium through MMIS, by contacting the MinnesotaCare enrollment representative, or with a copy of the client’s premium notice.

5. Determine eligibility for the MA household members. Use a manual monthly spenddown if MinnesotaCare expenses for other household members will be used to meet the spenddown. See §0913.21.07 (MinnesotaCare Inpatient Hospitalization) for spenddown information when MinnesotaCare enrollees apply for MA to help with inpatient hospital costs.

Apply the following MinnesotaCare expenses to meet an MA or GAMC spenddown for other household members:

PREGNANT WOMEN AND CHILDREN UNDER 21 FOR WHOM DHS RECEIVES FFP

• MinnesotaCare premiums. • Bills incurred outside the health plan network for which the household is financially responsible.

Do not allow the MinnesotaCare capitation payment or any other expenses paid by MinnesotaCare.

EXAMPLE:

Mark has Medicare coverage and is ineligible for MinnesotaCare. He has outstanding medical expenses and applies for MA on September 5. His wife, Angela, who is 6 months pregnant, and their 3-year-old daughter, Ranae, are enrolled in MinnesotaCare with a monthly premium of $58. Mark has a 6-month spenddown of $350. He has a dental bill for $300 from September and an old unpaid bill for a clinic visit for Ranae for $350 incurred in January, before Angela and Ranae enrolled in MinnesotaCare . MMIS case notes indicate that DHS receives FFP for Angela and Ranae. Allow the MinnesotaCare premium, Ranae's old unpaid bill, and Mark's bills toward his spenddown.

PREGNANT WOMEN AND CHILDREN UNDER 21 FOR WHOM DHS DOES NOT RECEIVE FFP

• The greater of:
• The MinnesotaCare premium.

OR

• The monthly capitation payment.
• Bills incurred outside the health plan network for which the household is financially responsible. • Expenses paid by MinnesotaCare for household members who are not enrolled in a health plan.

EXAMPLE:

Jesse, applies for MA on September 14 because of bills incurred due to injuries from a farm accident. He has a spenddown of $400. His wife, Donna, and their 5-year-old daughter, Anna, were enrolled in MinnesotaCare effective September 1 with a monthly premium of $98. DHS pays a monthly capitation payment of $212 for Donna and $102 for Anna. Donna is 4 months pregnant. She is a lawful permanent resident but does not meet the MA definition of a qualified non-citizen. Anna is a citizen. DHS receives FFP for Anna only.

Do not allow any of Anna's MinnesotaCare expenses toward Jesse's spenddown. Allow Donna's $212 capitation payment because it is greater than the MinnesotaCare premium. Also allow Jesse's bills from the accident.

PARENTS AND RELATIVE CARETAKERS IN FAMILIES WITH INCOMES OVER 275% FPG AND ADULTS WITHOUT CHILDREN

• The greater of:
• The MinnesotaCare premium.

OR

• The monthly capitation payment.
• Bills incurred outside the health plan network for which the household is financially responsible. • Expenses paid by MinnesotaCare for household members who are not enrolled in a health plan. • MinnesotaCare co-payments and inpatient hospitalization expenses.

EXAMPLE:

Elaine and her 4 children are enrolled in MinnesotaCare with a monthly premium of $150. The household’s income exceeds 175% FPG. DHS receives FFP for the children only. Elaine’s husband, Randy, has health insurance through work and is ineligible for MinnesotaCare. Randy applies for MA to cover $2,000 in dental expenses not covered by his health insurance. Randy has a $1,300 spenddown.

Do not allow any of the children’s MinnesotaCare expenses toward Randy’s spenddown. Allow the greater of the MinnesotaCare premium OR Elaine’s capitation payment. Also allow Randy’s insurance premiums and net medical bills.

PARENTS AND RELATIVE CARETAKERS WITH HOUSEHOLD INCOMES EQUAL TO OR LESS THAN 275% FPG FOR WHOM DHS RECEIVES FFP

• MinnesotaCare premiums. • Expenses incurred outside the health plan for which the household is financially responsible. • MinnesotaCare co-payments.

EXAMPLE:

Brett receives MA with a monthly spenddown of $100. His mother, Peggy, has recently been approved for MinnesotaCare and pays a monthly premium of $45. Her income is under 175% FPG. Peggy is enrolled in HealthPartners through MinnesotaCare and DHS receives FFP for her coverage. On July 12, Peggy is injured and is hospitalized. She incurs hospital charges of $15,000. She has a $10,000 inpatient hospital cap.

Apply Peggy's MinnesotaCare premium toward Brett's spenddown every month. Allow Peggy's inpatient charges in excess of the cap toward Brett's July spenddown.

PARENTS OR LEGAL GUARDIANS IN HOUSEHOLDS WITH INCOMES EQUAL TO OR LESS THAN 275% FPG FOR WHOM DHS DOES NOT RECEIVE FFP

• The greater of:
• The MinnesotaCare premium.

OR

• The monthly capitation payment.
• Bills incurred outside the health plan network for which the household is financially responsible. • Expenses paid by MinnesotaCare for household members who are not enrolled in a health plan. • MinnesotaCare co-payments and inpatient hospitalization expenses.

GAMC:

No provisions.

Return to Top

MINNESOTACARE INPATIENT HOSPITALIZATION 0913.21.07

MinnesotaCare:

Do not disenroll people for failing to apply for MA for inpatient hospitalization costs.

MA:

MinnesotaCare enrollees who have a basis of eligibility for MA may apply for MA to help with inpatient hospitalization costs not covered by MinnesotaCare but are not required to do so. MinnesotaCare enrollees who choose to apply for MA for inpatient hospitalization costs must apply at the county agency.

Take the following steps when you receive an MA application for costs associated with a MinnesotaCare inpatient hospitalization:

1. Ask the client if he/she wants MA for the month(s) of hospitalization only or ongoing. If the client wants MA for the month(s) of hospitalization only, determine MA eligibility for those months only on MAXIS. If the client wants ongoing MA, determine MA eligibility for the months of hospitalization and the remaining months in the budget period.

2. Determine which household members are active on MinnesotaCare by viewing the MMIS RELG screen for each person. Determine whether DHS receives FFP for the person and whether there is a $10,000 inpatient hospital cap according to the major program. See §0906.03.13 (MinnesotaCare Major Programs).

3. Determine if the applicant and other MinnesotaCare household members are enrolled in a health plan through MinnesotaCare by viewing the MMIS RPPH screen. In some cases, the monthly capitation payment to the health plan may be applied toward the spenddown. Authorized county staff may verify the capitation payment amounts by viewing the claims subsystem.

If the enrollment begin and end dates on RPPH do not correspond with the dates of inpatient hospitalization, the enrollee was receiving health coverage under fee-for-service and no capitation payments were made.

4. Verify the amount of the monthly MinnesotaCare premium through MMIS, by contacting the MinnesotaCare enrollment representative, or with a copy of the client’s premium statement.

5. Determine whether there is a spenddown for MA. Use an automated monthly spenddown. See §0913.05 (Which Spenddown Type to Use). Apply the following bills to the spenddown in the order listed for people enrolled in a health plan through MinnesotaCare:

a. The greater of EITHER the total monthly capitation payments for individuals who receive MinnesotaCare but for whom the state does not receive FFP, OR the monthly MinnesotaCare premium.

Add together capitation amounts for each non-FFP eligible individual. Do not use capitation payments for any family member for whom DHS receives FFP. If the sum of the capitation payments for non-FFP eligible individuals on MinnesotaCare is greater than the monthly premium, enter the capitation payment total on MAXIS. Enter the first day of the month as the date of service for the capitation payments.

If the sum of the capitation payments for non-FFP eligible individuals on MinnesotaCare is less than the monthly premium amount, enter the premium amount on MAXIS. Enter the first day of the month as the date of service for the monthly premium.

b. Any old or non-covered medical expenses. Use the appropriate bill type, service code, and actual date of service. MA will not reimburse bills incurred outside the health plan network that MinnesotaCare would have otherwise covered.

c. MinnesotaCare co-payments.

d. MinnesotaCare inpatient hospital expenses for the applicant. MinnesotaCare enrollees who receive services through a health plan may not receive medical bills to verify incurred expenses, such as hospitalization stays. The applicant may not be able to provide you with information on the costs incurred. Do not delay acting on the MA application if you cannot verify inpatient hospital expenses. If the client did not meet the spenddown after entering bills listed in 1-3 above, enter an inpatient hospital bill equal to the amount of the remaining spenddown.

Enter the actual date of service of the hospitalization. Do not enter any third party payment amounts, even if the hospitalization is covered by the MinnesotaCare health plan.

Apply the following bills in the order listed for people who were not enrolled in a health plan during the period of hospitalization:

a. Any old or non-covered medical expenses. Use the appropriate bill type, service code, and actual date of service.

b. The monthly MinnesotaCare premium. Enter the first day of the month as the date of service.

c. MinnesotaCare inpatient hospital bill. Enter the actual date of service. Use the gross amount of the bill and do not enter 3rd party payments.

GAMC:

MinnesotaCare enrollees may not receive GAMC, including GHO, for MinnesotaCare inpatient hospitalization costs. When an active MinnesotaCare enrollee applies for GAMC, approve GAMC for the month following the month of application if the applicant is eligible. If the MinnesotaCare capitation payment has been made, allow GAMC and MinnesotaCare to overlap for the first month of GAMC eligibility. The MinnesotaCare health plan must provide GAMC-covered services for that month.

When an active GAMC enrollee applies for MinnesotaCare, is approved, and pays the MinnesotaCare premium after 10-day notice cutoff, allow MinnesotaCare and GAMC to overlap until GAMC can be closed with a 10-day notice. GHO coverage ends on the date of hospital discharge, although the MMIS span remains open until the end of the month. Ten-day notice is not required. See §0904.09.11 (MinnesotaCare/MA Overlap) for more information on allowing overlapping eligibility spans on MMIS, including MMIS spans that extend beyond GHO termination.

Return to Top

BILLS REPORTED AFTER APPROVAL 0913.21.09

MinnesotaCare:

No provisions.

MA:

When applicants fail to report medical bills at the time of application but report the bills after the application has been approved, consider the additional bills if they were incurred in any of the retroactive months and were reported within 3 months of the month the bill was incurred. Adjust the spenddown and/or begin date as appropriate.

EXAMPLE:

Betty applies for MA on May 6. She does not request retroactive coverage. On May 15, MA is approved without a spenddown effective May 1. On May 26, Betty calls to report a medical bill incurred on February 10 and requests MA retroactive to February. Redetermine eligibility beginning with February. Approve MA effective February 1 if Betty is eligible without a spenddown. If she now has a spenddown, consider the February 10 bill toward meeting the spenddown.

EXAMPLE:

Barney applies for MA on June 10. He does not request retroactive coverage. He is approved with a 6-month spenddown effective June 5. On July 10, he calls to report a medical bill incurred on April 13 and requests MA retroactive to April. Redetermine eligibility beginning with April. Adjust the eligibility date if the April bill results in the spenddown being met earlier.

Do not redetermine eligibility if the client reports a bill more than 3 months after the month it was incurred, even if the bill was incurred within 3 months before the application month. The bill may be used to meet a future spenddown if it remains unpaid.

EXAMPLE:

Joelle applies for MA with MFIP on June 13. She does not request retroactive MA. On June 25, MFIP is approved with MA effective June 1. On September 5, Joelle calls to report a medical bill incurred on March 15. Do not redetermine eligibility since the bill was incurred more than 3 months before the month it was reported.

GAMC:

No provisions.

Return to Top

SPENDDOWN NOTICE REQUIREMENTS 0913.23

MinnesotaCare:

No provisions.

MA:

Spenddown cases have notice requirements in addition to those in §0916 (Notices). These requirements are the same for income reviews, applications, and recertifications.

Notify clients how you calculated the spenddown.

• For all spenddown types:

MAXIS will send completed income computation worksheets with the opening or denial notice.

Notify clients of their medical expense obligation. MAXIS does not notify clients which bills were used to meet the spenddown. Add worker comments to the notice to inform the client how the spenddown was met and which bills the client is responsible to pay. See TEMP Manual TE02.07.155 (MA Changes: Spenddown Problems and Workarounds).

• For automated monthly medical spenddowns:

Notify clients of their spenddown amount. DHS will tell them on the monthly Explanation of Medical Benefits (EOMB) which specific expenses are their obligation.

• For client option spenddowns:

Follow spenddown notice requirements under automated monthly spenddowns. Before the client option spenddown can begin, the client must sign an Agreement to Prepay Medical Assistance (MA) Spenddown (DHS-3081) to DHS. DHS will send client option bills. A late payment or non-payment does not affect the client's eligibility for MA/GAMC, nor does it result in loss of the prepayment option. The result of a late payment, non-payment, or partial payment is that the client's spenddown balance will be paid using potluck processing. See §0913.09.03 (Client Option Spenddown).

• For manual monthly medical spenddowns:

Notify clients of their date of eligibility and any remaining spenddown amount. DHS will tell them which specific expenses on or after that date are their obligation.

• For 6-month spenddowns:

Notify clients of their date of eligibility and any remaining spenddown amount. DHS will tell them which specific expenses on or after that date are their obligation.

• For LTC spenddowns:

Notify clients of their spenddown amount and their responsibility to apply this obligation toward LTCF costs. Adjustments to LTC spenddowns due to change in income do not require advance notice.

• For combination LTC/Medical spenddowns:

Notify clients of the spenddown amount. DHS will tell them which specific expenses in addition to the LTCF charges are their obligation.

GAMC:

No provisions.

Return to Top

Rate/Report this page Report/Rate this page