Apple Health for the Medically Needy and Spenddown overview
Purpose: To explain the Medically Needy (MN) program and spenddown.
WAC 182-500-0070 defines the Medically Needy program as follows:
"Medically needy (MN) or medically needy program (MNP)" is the state- and federally funded health care program available to specific groups of persons who would be eligible as categorically needy (CN), except their monthly income is above the CN standard. Some long-term care individuals with income and/or resources above the CN standard may also qualify for MN.
Base Periods and Retroactive Coverage
- Review the application to determine if the individual has applied for retroactive coverage. If not, contact the individual to determine if they have any unpaid or paid medical expenses that they incurred during that time period.
- Explain to the individual that they have the option to use the expenses they incurred and paid during the 3-month period or any expenses they have incurred but which remain unpaid towards meeting spenddown in the retroactive base period, or that they may apply the expenses towards their spenddown liability in the current base period.
- Explain the advantages or disadvantages of both options. If the individual chooses to use expenses that were incurred and paid within the 3-month retroactive period towards the current base period, we cannot then use the expenses towards establishing coverage in the retroactive period at a later date.
- ACES defaults to a 6-month certification period; however that may not be the best option for the individual. If possible, talk to the individual to determine their circumstances. Upcoming hospitalizations or other major expenses may make a difference in selecting a base period.
- If the spenddown amount is high, a 3-month base period may be to the individual's benefit.
- If the spenddown amount is low and the individual can easily meet it, a 6-month base period would provide medical coverage for a longer period of time.
Example: An individual has $30.00 per month in excess income.
Spenddown in this example would be $90.00 for a 3-month base period and $180.00 for a 6 month base period.
If the individual has $250.00 in qualifying medical expenses, a 6-month base period would be beneficial to the individual since they would have a longer period of eligibility.
If the same individual has no qualifying medical expenses at the time of application and anticipates no large medical needs, a 3-month base period may be in the individual's best interests. It would enhance the individual's opportunity to meet spenddown and obtain coverage.
Medical Providers and Spenddown Information
- When spenddown is met and benefits authorized, notify the medical service providers affected by spenddown. Those whose bills remain the responsibility of the individual may continue to pursue collection for those bills.
- Those provider bills which will be covered by the ProviderOne Card need to be billed to the Medicaid program, and the provider must cease billing the individual for those covered services.
- The agency is authorized to release spenddown information to providers without a signed release of information form if it is information necessary for the provider to correctly bill HCA. This information includes:
- the amount of the spenddown assigned to their bill (if the bill is a split bill)
- the specific expenses and dollar amounts of their bill(s) that were used
- the total dollar amount of the spenddown liability
- the balance of spenddown remaining to be met.
- If providers have questions related to spenddown, do not refer providers to the Medical Assistance Customer Service Center provider line (1-800-562-3022) as they are unable to provide this information. Instead, refer providers to:
- HCA MEDS (1-800-562-3022) for individuals on MN with spenddown who are pregnant or children; and
- DSHS Specialty Unit (1-877-501-2233) for other individuals on MN with spenddown.