ACES codes

This section provides additional clarification regarding ACES coding for medical expenses for spenddown.

Medicare Part A, Part B, Part C, or Part D Premiums Copayments Coinsurance charges that are not covered under the Qualified Medicare Beneficiary (QMB) Medicare Savings Program (MSP) Deductibles

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:

Allow premiums that the individual is or has been responsible to pay.

If S03, S05 or S06 is being approved to cover Part B premiums, allow the first two months premiums in the current base period.

Allow any premiums paid by the individual within the 3-month retroactive period if an MSP is not approved to cover this period. S05 or S06 can and should be approved for the retroactive period if requested – remember to notify the HCA Medicare Buy-In unit that you need retroactive coverage for Part B premiums.

Otherwise allow premiums as the expense is incurred.

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.

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 Washington Apple Health 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.

Private health insurance: Copayments (not premiums) Coinsurance charges Deductibles

Example

An individual has Regence Health insurance. He 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.

Private health insurance premiums

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.

Certain expenses, such as: Transportation to medical appointments or to pick up prescriptions. Items prescribed by an allowable provider but not covered by Medicaid, such as hearing aids. Prior unpaid charges that were denied by HCA as an uncovered expense. Prescribed vitamins, supplements, or over-the-counter medications, such as prenatal vitamins Orthodontic or chiropractic treatments Laser eye surgery

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.

Inpatient or outpatient services provided in a hospital setting. This includes emergency room visits, physician charges for services provided in the hospital, lab fees, x-rays etc.

Use initial date of service

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.

Any charges that are potentially payable by Medicaid, such as: Doctor’s visits Physical, speech or occupational therapy Specialist appointments Laboratory fees or X-rays Mental health services, etc.

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.

Prescription pharmacy expenses for non-Medicare-eligible individuals.

Prescription drug name required

When entering an RX expense, it is a required field to enter the name of the prescription drug.

Enter each prescription separately – do not lump prescription drugs into one expense, even if paid for together.

Ensure the individual has provided a receipt showing payment and is not just providing a list of prescriptions they are waiting to fill.

Do not allow the following as prescription expenses:

Self-paid Medicare-covered drug. A Medicare eligible individual cannot choose to self-pay for a Medicare covered drug and then use the expense toward meeting a spenddown.

Prescription drug not on plan formulary. A prescription drug that is not on the individual’s Medicare Part D plan’s formulary cannot be allowed towards spenddown unless the individual has requested an exception from their plan and has received a written denial.

Prescribed items that are not pharmaceuticals.