Procedures

Screen for eligibility for SSI and all other classes of ABD Medicaid.

AMN may be processed if the A/R is financially eligible for SSI and has an approved SMEU decision.

Follow the steps below to establish eligibility for ABD Medicaid under AMN.

Step 1 Accept the Medicaid application from the A/R and establish the six-month review period. Obtain a written statement of choice when a bill that could potentially be paid by Medicaid is used to meet SD for an ongoing month. Step 2 Conduct an interview. A phone interview is required for AMN applications. Determine all basic eligibility criteria except length of stay (LOS) and level of care (LOC). Complete Form DMA-285, Third Party Liability (TPL), if a resource exists that will pay for all or a portion of the A/R’s medical expenses. Step 3 Establish financial responsibility. Refer to 2500 ABD Financial Responsibility and Budgeting Overview Chapter 2500 ABD Financial Responsibility and Budgeting, to determine the following: whose income and resources to consider which AMNIL and AMN resource limit (individual or couple) to use which eligibility budget to complete. Step 4 Determine the countable resources of the A/R and/or deemor for the first month of the review period and all requested prior months and compare to the appropriate resource limit to determine resource eligibility. Step 5 Determine the income for the A/R and/or deemor. Step 6 De Facto Eligibility. If the A/R’s net countable income is less than or equal to the appropriate AMNIL, the A/R is De Facto eligible. Approve the A/R for Medicaid effective the first day of the month. If the case is not De Facto eligible, proceed to Step 7. Step 7 Spenddown Eligibility. If the A/R’s net countable income exceeds the appropriate AMNIL, the amount of the excess is the spenddown. Explain the spenddown concept to the A/R. Step 8 Determine whose expenses may be allowed as a deduction from the spenddown. Refer to Basic Considerations in this section. Step 9 Obtain copies of any unpaid medical expenses and those paid during the month for the individuals determined in Step 8. The A/R has the option to use the unpaid medical bill for the month incurred or in a subsequent month. If the A/R submits unpaid medical bills and wants them used in a spenddown budget other than the month in which it was incurred, have them complete and sign the Medically Needy Option Statement, which may be found in Appendix F - Forms. A large unpaid bill may be used as a rollover bill for consecutive or non-consecutive months. If a TPL exists, determine how much the TPL will pay on these bills and subtract this amount from the bill. Deduct only the remaining amount from the spenddown. Do not delay an eligibility determination simply because TPL cannot be ascertained or payment of the third party has not yet been received. This includes pending lawsuits/legal issues as long as the legal proceedings are reported to the TPL unit. Once verification of the TPL is received, reconcile the SD budget, and make adjustments if it is to the advantage of the A/R. Refer to Special Considerations and to Chart 2150.1 – Allowable Medical Expenses for AMN . If the A/R is a self-payer for the Medicare premium, allow the premium as the first deduction for each month of the review period. This is an exception to the policy of deducting bills in chronological order. The Medicare premium can be deducted the first of each month even if the A/R has other deductible bills incurred prior to the first of the month. Keep copies in the document imaging system of all medical bills used in the SD budget to prevent reuse of bills in subsequent SD budgets. Step 10 Arrange the allowable medical expenses in chronological order by date incurred, oldest to most recent. Deduct from the spenddown allowable medical expenses incurred prior to the month in chronological order. If the spenddown is met using prior medical expenses, approve Medicaid for the A/R from the first day of the budget period. Notify the A/R, PR, and DCH via the system of eligibility dates and first day liability. Do not send a Form 400 to DCH. If the spenddown is not met, proceed to Step 11. Step 11 Deduct from the spenddown allowable medical expenses incurred during the month in chronological order. Rank medical expenses incurred on the same day as follows: expenses incurred by an ineligible spouse or ineligible child expenses incurred by the A/R but not covered by Medicaid (non-covered items such as over-the-counter drugs or bills payable to non-Medicaid providers) remaining expenses, low to high, incurred by the A/R that are payable to a Medicaid provider. If the spenddown is met, proceed to Step 12. If the spenddown is not met, proceed to Step 14. Step 12 If the spenddown is met by bills in ranking order 1 or 2, Form 400 is not required. Complete the following actions: Approve the A/R for Medicaid to begin on the day in which the bill that brought the spenddown to zero (the break-even bill) was incurred. Send notice to the A/R. Include the BAD, the ending date of eligibility and the A/R’s Medicaid number. Complete Form 962 for any months you are unable to enter in the system. Enter $0 as the First Day Liability Amount. If the spenddown is met by bills in ranking order 3, Form 400 is required. Complete the following actions: Issue a Form 400 for the break-even bill showing the amount of the bill that was applied to the spenddown as the client liability. The Form 400 can be issued to either the A/R or to a provider. Discuss with the A/R and determine to whom the Form 400 should be issued. Issue Form 400 with a client liability of zero for any other Medicaid covered bills incurred on the BAD that were not used to meet the spenddown. The Form 962 must contain the following: “Form 400 Required”- “Y” The amount of the First Day Liability (FDL) Pharmacy is Break-even bill – “Y” or “N” “Eff Date” and “End Date” are the month, day, and year of the beginning and ending dates of eligibility. For group practices, indicate the specific individual who performed the medical service on Form 400, not the group name. Hospitals often submit a consolidated bill to the A/R. If requested to do so, issue Form(s) 400 to any individual provider whose bill was included in the consolidated bill. Include the FDL on the Form 400 for the hospital, but not on the Form 400 for the individual provider. Send notice to the A/R, including the BAD, FDL and the A/R’s Medicaid number. Step 13 If the spenddown is not met, place the case in suspense until enough medical expenses are incurred to meet the spenddown. Step 14 Subtract verified allowable medical expenses from the spenddown as they are presented by the A/R using Step 11 ranking order. Step 15 Deduct any medical expenses incurred during the month as they are provided by the A/R. Step 16 If the spenddown is met during the month, approve Medicaid as of the day spenddown is met. If the spenddown is not met during the month, begin the spenddown determination for the next month.