Purpose: This section provides additional clarification regarding ACES coding for medical expenses for spenddown.
Premiums. Individuals typically pay premiums for Part B and Part D plans and sometimes for Part C plans. The charges are allowed towards spenddown as follows:
Copayments. Individuals typically pay copayments for prescriptions under Part D, which vary depending on the drug and the Part D plan. These charges are allowed towards spenddown when the individual is responsible to pay for it. Medicaid only covers prescription drug costs for Medicare individuals if the drug is not covered by Medicare under the Part D plan but is covered by Medicaid.
Coinsurance. Individuals typically pay coinsurance charges under Parts A and B, which are generally 20% of the Medicare allowed charge. These charges are allowed towards spenddown unless the individual is also eligible for S03 coverage.
For example: An individual is on spenddown without QMB. Dr. Jones bills an individual $425. The Medicare allowed amount is $370 for this charge. Medicare pays 80% or $296 towards the bill, and the individual is legally obligated to pay the remaining 20% coinsurance amount of $74. Dr. Jones is not allowed to bill the individual for the remaining $55 -- the difference between $425 and the $370 that Medicare allowed. $74 is what is applied towards spenddown. The Explanation of Benefits (EOB) will show the allowed charges and the amount the individual is responsible for.
Deductibles. Individuals pay a standard deductible under Parts A and B, which are listed on the Medical income and resource standards chart. This amount is also typically shown on the individual's EOB. Deductibles are allowed towards spenddown unless the individual is also eligible for S03 coverage.
For example: An individual has Regence Health insurance. She pays $15 copayment for each doctor’s visit and has a $250 yearly deductible to meet before coverage begins. The $15 copayment would be coded “CO” in ACES. He brings you an insurance statement showing that he had a hospital visit in January and he is responsible for the first $250 of the bill. This would also be coded as “CO” in ACES.
Note: Do not code private health insurance premiums as "CO". Private health insurance premiums are coded on the MEDX screen, which reduces the total spenddown amount.
It is not necessary to code the expenses of a nonapplying spouse or other household members as "MU" in order for ACES to treat their expenses as "uncovered". Code expenses for nonmembers the same as if the nonmember were applying for coverage based upon the expense type.
Note: Always code hospital expense with the date the individual first entered the hospital. When reviewing hospital statements, use the initial date of service and not the statement date.
See Scope of Care for more information about services covered under the MN program. For questions regarding coverage for specific expenses, call the HCA Medical Assistance Customer Service Center at 1-800-562-3022.
Note: When entering an RX expense, it is a required field to enter the name of the prescription drug.
DO NOT allow the following as prescription expenses: