Spend Down Questions and Answers
March 27, 2012
Note: The following Q & A´s assume an individual is using the CHHA bill to meet his/her spend down.
|1||How are costs of services to be calculated for purposes of obtaining monthly Medicaid coverage?||To obtain monthly Medicaid coverage, costs of services are calculated based on the private pay rate for services provided in a given month. If the amount of the bill equals or exceeds the individual's spend down for the month, Medicaid coverage will be authorized for that month.|
|2||What spend down amount should be deducted on the Interim Claim and what spend down amount on the Final Adjusted Claim?||Once eligibility is established, the Interim Claim must include the spend down amount for the one calendar month in which the services begin. This assumes that the CHHA bill is being used to meet the spend down; if another bill has already been used to meet the spend down, then no spend down would be included in the Interim Claim. If a 60 day episode extends into three calendar months (and Medicaid eligibility was established for the three months), the Final Adjusted Claim must include the individual's total spend down amount paid to the CHHA provider for the three months. If the episode extends into two calendar months (and Medicaid eligibility was established for the two months), the total spend down amount for the two months should be entered on the Final Adjusted Claim. If other medical bills were used to meet the spend down in any month, that month's spend down would not be included.|
|3||What if a recipient does not meet his/her spend down during a 60 day episode?||No dates of service for episodic care may be billed in any calendar month of non-Medicaid eligibility. If an individual does not meet his/her spend down for a month during a 60 day episode, Medicaid may not be billed for that month.
See Q & A four and five for examples.
|4||What if a recipient does not meet his/her spend down for the first month of the 60 day episode?||If CHHA Medicaid services begin at the end of the month, and the cost of the services provided in that month, calculated at the private pay rate, is less than the spend down amount (individual does not meet his/her spend down), the individual is not Medicaid eligible and the 60 day episode would not begin until the first day of the following month on which there is a Medicaid billable service. Since the individual is not Medicaid eligible, he/she would pay the CHHA privately for any services received.
However, in an instance in which the first month is covered in part by Medicare, the CHHA has the option of "synching" the episode with Medicare by starting the Medicaid episode on the first day of the second month on which there is a Medicaid billable service and ending the Medicaid episode on the ending date of the Medicare episode.
|5||What if a recipient does not meet his/her spend down for the last month of the 60 day episode?||If an individual's 60 day episode ends at the beginning of a month (i.e. month #3), and the private pay rate for the number of days of service received in that month is less than the spend down amount (individual does not meet his/her spend down), the individual's episode would end on the last day of the previous month, provided that the recipient did not incur sufficient expenses with the CHHA or any other provider to meet the spend down requirement in month #3. The CHHA would not include the dates of service in the month of non-Medicaid eligibility in the final claim. For example, if the end of the episode included the first two days of the month and the private pay rate for the two days is less than the spend down amount, the episode would be billed as 58 days and would not include the last two days. This is true even if the last day of service in the previous month occurred prior to the 58th day, as long as the individual was not discharged and was continuing in the CHHA's care for the remainder of that month.|
|6||How does the CHHA bill Medicaid if the spend down amount is less than the private pay amount, but greater than the Medicaid rate?||If the individual's spend down amount is less than or equal to the private pay rate, the individual is Medicaid eligible. The individual owes the spend down amount to the provider and the provider will include the spend down amount on the claim submitted to Medicaid for the episodic payment.|
|7||If an individual meets his/her care plan goals and is discharged prior to the 60th day, is there any impact on the individual's spend down liability?||If an individual is discharged early from care due to having met the goals of the care plan, the spend down is only collected for the months in which the individual actually received care. For example, an individual is admitted on January 15th for a 60 day episode. On February 24th, it is determined that the individual has met his/her goals as outlined in the care plan. The individual is only liable for the spend down amount for January and February, even though the 60th day is in March. On the Final Adjusted Claim, only two months of spend down should be included.|
|8||If an individual has met his/her spend down in a month in which an episode of care ends, and then a new 60 day episode commences in the same month, how would the spend down be accounted for?||If an individual's 60 day episode ends July 15th, and the private pay rate for those 15 days equals or exceeds the spend down amount for July, the entire spend down is included on the Final Adjusted Claim for this episode. If a new 60 day episode commences July 16th (or anytime in July), the individual has already met his/her spend down for July, and there is no spend down applied toward the first month of the second episode. The Interim Claim would reflect no spend down.
If the private pay rate for the last days of the first episode is less than the spend down amount, the private pay amount for those days only would be included in the Final Adjusted Claim for the first episode. The remaining balance of the spend down would be included in the Interim Claim for the second episode.
|9||How would an instance in which, during the course of a 60 day episode, an individual is discharged prior to the end of the episode due to a hospitalization be claimed?||If, for the month of discharge, the private pay rate for the days of CHHA services received is less than the spend down amount, the individual would owe the private pay amount to the CHHA, and that amount would be included in the Final Adjusted Claim. The remainder of the spend down would be used toward the cost of the hospitalization. If the individual is discharged and the private pay rate for days of service equals or exceeds the amount of the spend down, the CHHA would end the episode on the date of discharge and include the spend down amount paid to the CHHA for that month on the Final Adjusted Claim.|