Page 316

NOTIFICATION OF SPEND-DOWN STATUS 7.8

An applicant who is ineligible due to being over-income shall be sent a denial notice which informs him/her that s/he should contact the Spend-Down Unit. If the applicant is over-income and has submitted his/her medical bills to the SSR, the SSR should transfer the file and the medical bills directly to the Spend-Down Unit and send the applicant a denial notice which indicates that his/her file, including the medical bills, has been transferred to the Spend-Down Unit.

An applicant who meets the prospective spend-down deductible must be notified in writing of his/her eligibility for MA. This notification must include the dates for which the applicant is eligible for coverage and a statement that the Department will not pay for medical expenses used to meet the prospective spend-down deductible.

If eligibility under the spend-down provision has been considered for a retroactive budget period but has not been established because incurred medical bills do not exceed the spend-down deductible, the applicant must be notified in writing that retroactive spend-down eligibility is denied. This requirement for notification must be met even if the application has also been considered for prospective eligibility for MA, and a notice of approval or denial of prospective eligibility is sent.

INTERIM CHANGES 7.9

The SSR must assess the effect of any interim change that occurs during the prospective spend-down budget period. A change in income that occurs before a prospective spend-down deductible has been met requires the recalculation of the prospective spend-down deductible. The months in the budget period, however, are not affected.

A change in income that occurs after MA eligibility has been established with a spend-down deductible may require changes in the group's spend-down deductible and may affect the group's eligibility under the spend-down provision. If a previously eligible group must now meet a spend-down deductible, the SSR should conditionally deny the group.

If an additional prospective spend-down deductible is calculated, eligibility must be conditionally terminated. Eligibility may be re-approved if the applicant meets the amount of the additional spend- down deductible. In addition, if income increases for a group without a spend-down deductible, they may now be subject to meeting a spend-down liability. Example 3

Prospective Eligibility

Ms. Jones applies for Medicaid in November and is found to be over-income. She wants to see her past unpaid medical expenses toward prospective eligibility. Over the seven-month period prior to applying for Medicaid, Ms. Jones accumulated $2,200 in unpaid medical bills. Her spend-down deductible is $400 per month, or $2,400 over the six-month prospective eligibility period. She expects to spend $500 on medication in November alone. By using the cumulative spend-down method, her past unpaid liabilities plus her expenses in November are likely to exceed her $2,400 spend -down limit. Once this spend-down liability is met, all additional covered medical expenses will be paid for the Medicaid.