SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: October 20, 2008.
Purpose: The department has started the permanent rule-making process to amend this rule, but adopting an emergency rule in the interim is essential so the program is compliant with the federal regulations that allow both paid and unpaid medical expenses incurred by a client during the retroactive eligibility period to be applied towards the client's spenddown in the current eligibility period. Treatment of hospital bills will no longer be singled out, but will mirror the federal rule by eliminating specific references to hospital bills and amending the language regarding the prioritization of expenses.
Citation of Existing Rules Affected by this Order: Amending WAC 388-519-0110.
Statutory Authority for Adoption: RCW 74.04.050, 74.08.090, 74.09.500.
Other Authority: 42 C.F.R. 435.831 (3)(e) and (f).
Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; and that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.
Reasons for this Finding: This emergency filing is necessary to correct the text in the emergency rule filed for WAC 388-519-0110 under WSR 08-21-100 on October 17, 2008. Some individuals may be adversely affected if this rule is not changed to mirror federal requirements. Adoption of the rule ensures compliance with federal requirements and continuation of federal funds. The department has initiated the permanent rule-making process with a preproposal statement of inquiry file[d] as WSR 08-19-032.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 1, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: October 17, 2008.
Stephanie E. Schiller
(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)) other medical expenses which were incurred
and paid during the three month retroactive base period, if
eligibility for medical was not established for that 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 current base period; and
(f) Sixth)) (e) Fifth, other medical expenses,
potentially payable by the MN program which are owed by the
(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 either paid or unpaid and
incurred during the base period; ((
(iii) Be for medical services incurred and paid during the three month retroactive base period if eligibility for medical was not established in that base period. Paid expenses which meet this requirement may be applied towards the current base period; or
(iv) Be for medical services paid 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 WAC 388-501-0060 and 388-501-0065, 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 for services rendered to the client 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) The medical expenses applied to the spenddown amount are the client's financial obligation and are not reimbursed by the department (see WAC 388-502-0100).
(16) 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, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-519-0110, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. 06-13-042, § 388-519-0110, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, and 74.08.090. 05-08-093, § 388-519-0110, filed 4/1/05, effective 5/2/05; 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.]