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Title 8: Medicaid Page 15 Iowa Department of Health and Human Services Employees’ Manual Chapter A: Administration Benefits Revised January 13, 2023 Recovery

2. Mrs. B has an overpayment for the months of November through March. There are no retroactive months. This is one Medicaid claim with three certification periods.

Spenddown amounts are determined for the following certification periods: ▪ November/December Spenddown of: $ 1,782.88 ▪ January/February Spenddown of: $ 1,782.88 ▪ March Spenddown of: $ 891.44

Medicaid paid the following medical expenses for Mrs. B: ▪ November/December

$ 5,000 ▪ January/February

$ 400 ▪ March

$ 1,000 Certification Period Spenddown Medicaid Paid Overpayment November/December $ 1,782.88 $ 5,000

$ 1782.88 January/February $ 1782.88 $ 400

$ 400.00 March $ 891.44 $ 1,000

$ 891.44 Total amount of overpayment = $3074.32 ($1782.88 +$400 + $891.44) NOTE: When calculating an overpayment that will include a Medically Needy spenddown, do not update the Medically Needy spenddown amounts on the Automated Benefit Calculation (ABC) system or in the Medicaid Management Information: Medically Needy (MMIS MN) subsystem. 4. When a member appeals an overpayment because a prescription was used to meet spenddown, but the member did not receive the prescription, include the following statement on the appeal summary:

“When a pharmacy submits claims for payment for prescriptions to Iowa Medicaid Enterprise (IME), the claim will be denied if the person is not eligible for Medicaid. If the person is conditionally eligible for Medically Needy with a spenddown at that time, the Medically Needy subsystem applies the denied claim to the spenddown for that certification period. “The system assumes that the service was received when Medicaid claims are submitted. When the person is not eligible for Medicaid, the pharmacy may not give the prescription to the person if the person cannot pay for it. When this happens, the amount of the claim is incorrectly applied towards meeting the spenddown for Medically Needy. “There are also situations where the pharmacy fills a prescription that is not picked up. Again, the claim has been used to meet the spenddown when the person has not received the service. “In either situation, when the pharmacy is aware that Medically Needy is involved, the pharmacy submits a deletion form to IME to remove the claim from being used to meet spenddown. “If the spenddown has not been met, the claim is deleted. If spenddown has already been met, then the person has become Medicaid-eligible without having incurred all of the medical expenses used to establish eligibility and may have an overpayment.