WAC 182-519-0110 Spenddown of excess income for the medically needy program

Effective January 27, 2019

A person who applies for Washington apple health (WAH) and is eligible for medically needy (MN) coverage with a spenddown may choose a three-month or a six-month base period. A base period is a time period used to compute the spenddown liability amount. The months must be consecutive calendar months, unless a condition in subsection (4) of this section applies.

A base period begins on the first day of the month a person applies for WAH, unless a condition in subsection (4) of this section applies.

A person may request a separate base period to cover up to three calendar months immediately before the month of application. This is called a retroactive base period.

A base period may vary from the terms in subsections (1), (2), or (3) of this section if: A three-month base period would overlap a previous eligibility period; The person has countable resources over the applicable standard for any part of the required base period; The person is not or will not be able to meet the temporary assistance to needy families (TANF)-related or supplemental security income (SSI)-related requirement for the required base period; The person is eligible for categorically needy (CN) coverage for part of the required base period; or The person was not otherwise eligible for MN coverage for each month of the retroactive base period.

The medicaid agency or its designee calculates a person's spenddown liability. The MN countable income from each month of the base period is compared to the effective medically needy income level (MNIL) under WAC 182-519-0050 . Income over the effective MNIL standard (based on the person's household size) in each month in the base period is added together to determine the total spenddown amount.

If household income varies and a person's MN countable income falls below the effective MNIL for one or more months, the difference offsets the excess income in other months of the base period. See WAC 182-519-0100 (7) if a spenddown amount results in zero dollars and cents.

If a person's income decreases, the agency or its designee approves CN coverage for each month in the base period when the person's countable income and resources are equal to or below the applicable CN standards. Children age eighteen and younger and pregnant women who become CN eligible in any month of the base period are continuously eligible for CN coverage for the remainder of the certification, even if there is a subsequent increase in income.

Once a person's spenddown amount is determined, qualifying medical expenses are deducted. A qualifying medical expense must: Be an expense for which the person is financially liable; Not have been used to meet another spenddown; Not be the confirmed responsibility of a third party. The agency or its designee allows the entire expense if a third party has not confirmed its coverage of the expense within: Forty-five days of the date of service; or Thirty days after the base period ends. Be an incurred expense for the person: The person's spouse; A family member residing in the person's home for whom the person is financially responsible; or A relative residing in the person's home who is financially responsible for the person. Meet one of the following conditions: Be an unpaid liability at the beginning of the base period; Be for paid or unpaid medical services incurred during the base period; Be for medical services incurred and paid during the three-month retroactive base period if eligibility for WAH was not established in that base period. Paid expenses that meet this requirement may be applied towards the current base period; or Be for medical services incurred during a previous base period, either unpaid or paid, if it was necessary for the person to make a payment due to delays in the certification for that base period.

An exception to subsection (8) of this section exists for qualifying medical expenses paid on the person's behalf by a publicly administered program during the current or the retroactive base period. The agency or its designee uses the qualifying medical expenses to meet the spenddown liability. To qualify for this exception, the program must: Not be federally funded or make payments from federally matched funds; Not pay the expenses before the first day of the retroactive base period; and Provide proof of the expenses paid on the person's behalf.

Once the agency or its designee determines the expenses are a qualified medical expense under subsection (8) or (9) of this section, the expenses are subtracted from the spenddown liability to determine the date the person's eligibility for medical coverage begins. Qualifying medical expenses are deducted in the following order: First, medicare and other health insurance deductibles, coinsurance charges, enrollment fees, copayments, and premiums that are the person's responsibility under medicare Part A through Part D. (Health insurance premiums are income deductions under WAC 182-519-0100 (5)); Second, medical expenses incurred and paid by the person during the three-month retroactive base period if eligibility for WAH was not established in that base period; Third, current payments on, or unpaid balance of, medical expenses incurred before the current base period that were not used to establish eligibility for medical coverage in another base period. The agency or its designee sets no limit on the age of an unpaid expense; however, the expense must be a current liability and be unpaid at the beginning of the base period; Fourth, other medical expenses that are not covered by the agency's or its designee's medical programs, minus any third-party payments that apply to the charges. A licensed health care provider must provide or prescribe the items or services allowed as a medical expense; Fifth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges). This deduction is allowed even if payment is denied for these services because they exceed the agency's or its designee's limits on amount, duration, or scope of care. Scope of care is described in WAC 182-501-0060 and WAC 182-501-0065 ; and Sixth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges) and that are within the agency's or its designee's limits on amount, duration, or scope of care.

If a person submits verification of qualifying medical expenses with his or her application that meet or exceed the spenddown liability, the person is eligible for MN medical coverage for the remainder of the base period unless their circumstances change. See WAC 182-504-0105 to determine which changes must be reported to the agency or its designee. The beginning of eligibility is determined under WAC 182-504-0020 .

If a person cannot meet the spenddown amount when the application is submitted, the person is not eligible until he or she provides proof of additional qualifying expenses that meet the spenddown liability.

Each dollar of a qualifying medical expense may count once against a spenddown period that leads to eligibility for MN coverage. However, medical expenses may be used more than once if: The person did not meet his or her total spenddown liability and become eligible in a previous base period and the bill remains unpaid; or The medical expense was incurred and paid within three months of the current application, and the agency or its designee could not establish WAH eligibility for the person in the retroactive base period.

The person must provide the proof of qualifying medical expense information to the agency or its designee within thirty days after the base period ends, unless there is a good reason for delay.

Once a person meets the spenddown requirement and the certification begin date is established, newly identified expenses are not considered toward that spenddown unless: There is a good reason for the delay in submitting the expense; or The agency or its designee made an error when determining the correct begin date.

Good reasons for delay in providing medical expense information to the agency or its designee include, but are not limited to: The person did not receive a timely bill from his or her medical provider or insurance company; The person has medical issues that prevent him or her from submitting proof on time; or The person meets the criteria for needing equal access under chapter WAC 182-503-0120 .

The agency or its designee does not pay for any expense or portion of an expense used to meet a person's spenddown liability.

If an expense is potentially payable under the MN program, and only a portion of the medical expense is assigned to meet spenddown, the medical provider must not: Bill the person for more than the amount assigned to the remaining spenddown liability; or Accept or retain any additional amount for the covered service from the person. Any additional amount may be billed to the agency or its designee. See WAC 182-502-0160 , Billing a client.

The agency or its designee determines whether any payment is due to the medical provider on medical expenses partially assigned to meet a spenddown liability under WAC 182-502-0100 .

If the medical expense assigned to spenddown was incurred outside of a period of MN eligibility, or if the expense is not covered by WAH, the agency or its designee does not pay any portion of the bill.

This is a reprint of the official rule as published by the Office of the Code Reviser . If there are previous versions of this rule, they can be found using the Legislative Search page .