(1) A person who
applies for Washington apple health (WAH) and is eligible for medically needy
(MN) coverage with a spenddown may choose a three-month or a six-month base
period. A base period is a time period used to compute the spenddown liability
amount. The months must be consecutive calendar months, unless a condition in
subsection (4) of this section applies.
(2) A base period begins on the first day of
the month a person applies for WAH, unless a condition in subsection (4) of
this section applies.
(3) A person
may request a separate base period to cover up to three calendar months
immediately before the month of application. This is called a retroactive base
period.
(4) A base period may vary
from the terms in subsections (1), (2), or (3) of this section if:
(a) A three-month base period would overlap a
previous eligibility period;
(b)
The person has countable resources over the applicable standard for any part of
the required base period;
(c) The
person is not or will not be able to meet the temporary assistance to needy
families (TANF)-related or supplemental security income (SSI)-related
requirement for the required base period;
(d) The person is eligible for categorically
needy (CN) coverage for part of the required base period; or
(e) The person was not otherwise eligible for
MN coverage for each month of the retroactive base period.
(5) The medicaid agency or its designee
calculates a person's spenddown liability. The MN countable income from each
month of the base period is compared to the effective medically needy income
level (MNIL) under WAC
182-519-0050.
Income over the effective MNIL standard (based on the person's household size)
in each month in the base period is added together to determine the total
spenddown amount.
(6) If household
income varies and a person's MN countable income falls below the effective MNIL
for one or more months, the difference offsets the excess income in other
months of the base period. See WAC
182-519-0100(7)
if a spenddown amount results in zero dollars and cents.
(7) If a person's income decreases, the
agency or its des-ignee approves CN coverage for each month in the base period
when the person's countable income and resources are equal to or below the
applicable CN standards. Children age eighteen and younger and pregnant women
who become CN eligible in any month of the base period are continuously
eligible for CN coverage for the remainder of the certification, even if there
is a subsequent increase in income.
(8) Once a person's spenddown amount is
determined, qualifying medical expenses are deducted. A qualifying medical
expense must:
(a) Be an expense for which the
person is financially liable;
(b)
Not have been used to meet another spenddown;
(c) Not be the confirmed responsibility of a
third party. The agency or its designee allows the entire expense if a third
party has not confirmed its coverage of the expense within:
(i) Forty-five days of the date of service;
or
(ii) Thirty days after the base
period ends.
(d) Be an
incurred expense for the person:
(i) The
person's spouse;
(ii) A family
member residing in the person's home for whom the person is financially
responsible; or
(iii) A relative
residing in the person's home who is financially responsible for the
person.
(e) Meet one of
the following conditions:
(i) Be an unpaid
liability at the beginning of the base period;
(ii) Be for paid or unpaid medical services
incurred during the base period;
(iii) Be for medical services incurred and
paid during the three-month retroactive base period if eligibility for WAH was
not established in that base period. Paid expenses that meet this requirement
may be applied towards the current base period; or
(iv) Be for medical services incurred during
a previous base period, either unpaid or paid, if it was necessary for the
person to make a payment due to delays in the certification for that base
period.
(9)An
exception to subsection (8) of this section exists for qualifying medical
expenses paid on the person's behalf by a publicly administered program during
the current or the retroactive base period. The agency or its designee uses the
qualifying medical expenses to meet the spenddown liability. To qualify for
this exception, the program must:
(a) Not be
federally funded or make payments from federally matched funds;
(b) Not pay the expenses before the first day
of the retroactive base period; and
(c) Provide proof of the expenses paid on the
person's behalf.
(10)
Once the agency or its designee determines the expenses are a qualified medical
expense under subsection (8) or (9) of this section, the expenses are
subtracted from the spenddown liability to determine the date the person's
eligibility for medical coverage begins. Qualifying medical expenses are
deducted in the following order:
(a) First,
medicare and other health insurance deduct-ibles, coinsurance charges,
enrollment fees, copayments, and premiums that are the person's responsibility
under medicare Part A through Part D. (Health insurance premiums are income
deductions under WAC
182-519-0100(5)
);
(b) Second, medical expenses
incurred and paid by the person during the three-month retroactive base period
if eligibility for WAH was not established in that base period;
(c) Third, current payments on, or unpaid
balance of, medical expenses incurred before the current base period that were
not used to establish eligibility for medical coverage in another base period.
The agency or its designee sets no limit on the age of an unpaid expense;
however, the expense must be a current liability and be unpaid at the beginning
of the base period;
(d) Fourth,
other medical expenses that are not covered by the agency's or its designee's
medical programs, minus any third-party payments that apply to the charges. A
licensed health care provider must provide or prescribe the items or services
allowed as a medical expense;
(e)
Fifth, other medical expenses incurred by the person during the base period
that are potentially payable by the MN program (minus any confirmed third-party
payments that apply to the charges). This deduction is allowed even if payment
is denied for these services because they exceed the agency's or its designee's
limits on amount, duration, or scope of care. Scope of care is described in WAC
182-501-0060
and
182-501-0065;
and
(f) Sixth, other medical
expenses incurred by the person during the base period that are potentially
payable by the MN program (minus any confirmed third-party payments that apply
to the charges) and that are within the agency's or its designee's limits on
amount, duration, or scope of care.
(11) If a person submits verification of
qualifying medical expenses with his or her application that meet or exceed the
spenddown liability, the person is eligible for MN medical coverage for the
remainder of the base period unless their circumstances change. See WAC
182-504-0105
to determine which changes must be reported to the agency or its designee. The
beginning of eligibility is determined under WAC
182-504-0020.
(12) If a person cannot meet the spenddown
amount when the application is submitted, the person is not eligible until he
or she provides proof of additional qualifying expenses that meet the spenddown
liability.
(13) Each dollar of a
qualifying medical expense may count once against a spenddown period that leads
to eligibility for MN coverage. However, medical expenses may be used more than
once if:
(a) The person did not meet his or
her total spenddown liability and become eligible in a previous base period and
the bill remains unpaid; or
(b) The
medical expense was incurred and paid within three months of the current
application, and the agency or its designee could not establish WAH eligibility
for the person in the retroactive base period.
(14) The person must provide the proof of
qualifying medical expense information to the agency or its designee within
thirty days after the base period ends, unless there is a good reason for
delay.
(15) Once a person meets the
spenddown requirement and the certification begin date is established, newly
identified expenses are not considered toward that spenddown unless:
(a) There is a good reason for the delay in
submitting the expense; or
(b) The
agency or its designee made an error when determining the correct begin
date.
(16) Good reasons
for delay in providing medical expense information to the agency or its
designee include, but are not limited to:
(a)
The person did not receive a timely bill from his or her medical provider or
insurance company;
(b) The person
has medical issues that prevent him or her from submitting proof on time;
or
(c) The person meets the
criteria for needing equal access under WAC
182-503-0120.
(17) The agency or its designee
does not pay for any expense or portion of an expense used to meet a person's
spenddown liability.
(18) If an
expense is potentially payable under the MN program, and only a portion of the
medical expense is assigned to meet spenddown, the medical provider must not:
(a) Bill the person for more than the amount
assigned to the remaining spenddown liability; or
(b) Accept or retain any additional amount
for the covered service from the person. Any additional amount may be billed to
the agency or its designee. See WAC
182-502-0160,
Billing a client.
(19)
The agency or its designee determines whether any payment is due to the medical
provider on medical expenses partially assigned to meet a spenddown liability
under WAC
182-502-0100.
(20) If the medical expense assigned to
spenddown was incurred outside of a period of MN eligibility, or if the expense
is not covered by WAH, the agency or its designee does not pay any portion of
the bill.