SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Preproposal statement of inquiry was filed as WSR 04-23-064.
Title of Rule and Other Identifying Information: WAC 388-519-0110 Spenddown of excess income for the medically needy program.
Hearing Location(s): Blake Office Park East (behind Goodyear Courtesy Tire), Rose Room, 4500 10th Avenue S.E., Lacey, WA, on March 22, 2005, at 10:00 a.m.
Date of Intended Adoption: Not sooner than March 23, 2005.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA, e-mail firstname.lastname@example.org, fax (360) 664-6185, by 5:00 p.m., March 22, 2005.
Assistance for Persons with Disabilities: Contact Fred Swenson, DSHS Rules Consultant, by March 18, 2005, TTY (360) 664-6178 or (360) 664-6097.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The change is needed in order to comply with federal regulations. Under 42 C.F.R. § 435.831 (f)(1), medical expenses either paid or unpaid during the base period can be used to reduce spenddown.
Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, and 74.08.090.
Statute Being Implemented: 42 C.F.R. § 435.831 (f)(1).
Rule is necessary because of federal law, 42 C.F.R. § 435.831 (f)(1).
Name of Proponent: Department of Social and Health Services, governmental.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Wendy Forslin, P.O. Box 45534, Olympia, WA 98504-5534, (360) 725-1343.
No small business economic impact statement has been prepared under chapter 19.85 RCW. This change does not affect small businesses.
A cost-benefit analysis is not required under RCW 34.05.328. This client financial eligibility rule revision is exempt from the provisions of RCW 34.05.328 per RCW 34.05.328 (5)(b)(vii).
February 8, 2005
Andy Fernando, Manager
Rules and Policies Assistance Unit3510.2
(2) A person's base period begins on the first day of the month of application, subject to the exceptions in subsection (4) of this section.
(3) A separate base period may be made for a retroactive period. The retroactive base period is made up of the three calendar months immediately prior to the month of application.
(4) A base period may vary from the terms in subsections (1), (2), or (3) of this section if:
(a) A three month base period would overlap a previous eligibility period; or
(b) A client is not or will not be resource eligible for the required base period; or
(c) The client is not or will not be able to meet the TANF-related or SSI-related requirement for the required base period; or
(d) The client is or will be eligible for categorically needy (CN) coverage for part of the required base period; or
(e) The client was not otherwise eligible for MN coverage for each of the months of the retroactive base period.
(5) The amount of a person's "spenddown" is calculated by the department. The MN countable income from each month of the base period is compared to the MNIL. The excess income from each of the months in the base period is added together to determine the "spenddown" for the base period.
(6) If income varies and a person's MN countable income falls below the MNIL for one or more months, the difference is used to offset the excess income in other months of the base period. If this results in a spenddown amount of zero dollars and cents, see WAC 388-519-0100(5).
(7) Once a person's spenddown amount is known, their qualifying medical expenses are subtracted from that spenddown amount to determine the date of eligibility. The following medical expenses are used to meet spenddown:
(a) First, Medicare and other health insurance deductibles, coinsurance charges, enrollment fees, or copayments;
(b) Second, medical expenses which would not be covered by the MN program;
(c) Third, hospital expenses paid by the person during the base period;
(d) Fourth, hospital expenses, regardless of age, owed by the applying person;
(e) Fifth, other medical expenses, potentially payable by the MN program, which have been paid by the applying person during the base period; and
(f) Sixth, other medical expenses, potentially payable by the MN program which are owed by the applying person.
(8) If a person meets the spenddown obligation at the time of application, they are eligible for MN medical coverage for the remainder of the base period. The beginning date of eligibility would be determined as described in WAC 388-416-0020.
(9) If a person's spenddown amount is not met at the time of application, they are not eligible until they present evidence of additional expenses which meets the spenddown amount.
(10) To be counted toward spenddown, medical expenses must:
(a) Not have been used to meet a previous spenddown; and
(b) Not be the confirmed responsibility of a third party. The entire expense will be counted unless the third party confirms its coverage within:
(i) Forty-five days of the date of the service; or
(ii) Thirty days after the base period ends; and
(c) Meet one of the following conditions:
(i) Be an unpaid liability at the beginning of the base period and be for services for:
(A) The applying person; or
(B) A family member legally or blood-related and living in the same household as the applying person.
(ii) Be for medical services ((
received and)) either paid
(( for)) or unpaid and incurred during the base period; or
(iii) Be for medical services ((
received and)) paid
(( for)) and incurred during a previous base period if that
client payment was made necessary due to delays in the
certification for that base period.
(11) An exception to the provisions in subsection (10) of this section exists. Medical expenses the person owes are applied to spenddown even if they were paid by or are subject to payment by a publicly administered program during the base period. To qualify, the program cannot be federally funded or make the payments of a person's medical expenses from federally matched funds. The expenses do not qualify if they were paid by the program before the first day of the base period.
(12) The following medical expenses which the person owes are applied to spenddown. Each dollar of an expense or obligation may count once against a spenddown cycle that leads to eligibility for MN coverage:
(a) Charges for services which would have been covered by the department's medical programs as described in chapter 388-529 WAC, less any confirmed third party payments which apply to the charges; and
(b) Charges for some items or services not typically covered by the department's medical programs, less any third party payments which apply to the charges. The allowable items or services must have been provided or prescribed by a licensed health care provider; and
(c) Medical insurance and Medicare copayments or coinsurance (premiums are income deductions under WAC 388-519-0100(4)); and
(d) Medical insurance deductibles including those Medicare deductibles for a first hospitalization in sixty days.
(13) Medical expenses may be used more than once if:
(a) The person did not meet their total spenddown amount and did not become eligible in that previous base period; and
(b) The medical expense was applied to that unsuccessful spenddown and remains an unpaid bill.
(14) To be considered toward spenddown, written proof of medical expenses must be presented to the department. The deadline for presenting medical expense information is thirty days after the base period ends unless good cause for delay can be documented.
(15) Once a person meets their spenddown and they are issued a medical identification card for MN coverage, newly identified expenses cannot be considered toward that spenddown. Once the application is approved and coverage begins the beginning date of the certification period cannot be changed due to a clients failure to identify or list medical expenses.
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-519-0110, filed 7/31/98, effective 9/1/98. Formerly WAC 388-518-1830, 388-518-1840, 388-519-1905, 388-519-1910, 388-519-1930 and 388-522-2230.]