Questions and Answers

Q & A Topics

General | Billing and Payment | Chronic Illness Demonstration Project (CIDP) | Health Home Design | Health Home Development Funds | Health Home Letter of Intent/Applications/Provider Enrollment/Application Form | Health Home Network | Health Information Technology | Managed Care | Member Forms | Population Assignment/ Eligibility (Patient Tracking System) | Quality Metrics and Evaluation (CMART) | Spend Down | Targeted Case Management (TCM) |

Spend Down

  1. We have a number of individuals who enter and leave Health Homes because they lose their Medicaid or do not meet their spenddown requirements. Should these members be disenrolled?
  2. In planning for enrolling children in Health Homes, the fluctuating Medicaid eligibility will be complex. Children move on and off Medicaid due to changes in household income and circumstances and also move between "deemed" Medicaid and community Medicaid (#´s change and gaps in accessing approval occur).
  3. Can the Health Home bill be used for spenddown?
  4. Are there specific locations to send the Pay–In portion in New York City? What address should I send the Pay–In payments to?
  5. What does "excess resources verified" mean?
  6. What if the eligibility file states "Provisional Coverage"?
  7. If an individual has met his/her spenddown with other providers, can Health Homes submit a claim?
  8. Can spenddown individuals be sent to a collection agency?
  9. If an individual does not submit documentation to satisfy his/her monthly spenddown, would he/she remain enrolled in the Health Home?
  10. Who is a principal provider?
  11. For individuals who meet their spenddown monthly by submitting proof each month, can Health Homes bill?
  12. When bills/receipts/payments are submitted timely to satisfy the monthly spenddown, there can be a delay in updating the coverage from provisional to outpatient or inpatient (depending on what type of bill was submitted). Is there a policy to support how long (days) a district has to update the coverage?
  13. How does spenddown work with US residents versus non US residents?
  14. What entity would be the principal provider for the spenddown if the Health Home member is also serviced by an MLTC?
   Archived Questions
1. We have a number of individuals who enter and leave Health Homes because they lose their Medicaid or do not meet their spenddown requirements. Should these members be disenrolled?

Individuals with a monthly spenddown should not be disenrolled. The individual should remain on the Health Home enrollment file but the PMPM (Per Member Per Month) cannot be billed unless the spenddown has been met and coverage authorized for the month is compatible with the Health Home Program. Disenrollment, withdrawal of consent and subsequent reenrollment of the client, would not be required. The Department has a "Pended" status in the MAPP HHTS (Health Home Tracking System) that can be used in this instance.

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2. In planning for enrolling children in Health Homes, the fluctuating Medicaid eligibility will be complex. Children move on and off Medicaid due to changes in household income and circumstances and also move between "deemed" Medicaid and community Medicaid (#´s change and gaps in accessing approval occur).

Children currently receive 12 months of "continuous coverage" from the date of the eligibility determination, meaning that they´re guaranteed 12 months of coverage, regardless of any income changes during the year.

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3. Can the Health Home bill be used for spenddown?

No. Beginning December 2016, the Department changed the rates for Health Home payments to a more streamlined payment. The Health Home rate is, however, based on the individual´s circumstances each month and can therefore fluctuate accordingly. At this time, Health Home bills cannot be used toward a member´s spenddown.

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4. Are there specific locations to send the Pay–In portion in New York City? What address should I send the Pay–In payments to?

Yes. Individuals participating in the Pay–In program in New York City should send their payment to the following address: HRA Division of Accounts Receivable and Billing (DARB), 180 Water Street, 9th Floor, New York, NY 10038.

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5. What does "excess resources verified" mean?

Individuals who are 65 years of age or older, certified blind or certified disabled are subject to a resource test. If an individual has documented his/her current resources, he/she is eligible for outpatient long term care services in the community. The term "reference to resources" refers to an individual who, in addition to having a resource test, has an income test.

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6. What if the eligibility file states "Provisional Coverage"?

There are specific coverage codes for individuals with limited services packages depending on the level of resource documentation they have provided. The "provisional coverage" code would be assigned to individuals who have had a resource test and documented their resources but who may also have excess income and have not yet provided bills/receipts/payments at or above that level. Functionally, they have no coverage at all until they meet their spenddown.

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7. If an individual has met his/her spenddown with other providers, can Health Homes submit a claim?

Yes, if an individual has met his/her monthly spenddown requirement, a Health Home can submit a claim for Health Home services that month as long as a core service was provided.

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8. Can spenddown individuals be sent to a collection agency?

Yes.

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9. If an individual does not submit documentation to satisfy his/her monthly spenddown, would he/she remain enrolled in the Health Home?

If an individual has provisional coverage but has not met his/ her spenddown, the individual can remain enrolled in the Health Home if they are otherwise eligible, but the Health Home cannot bill for services unless the individual has met the spenddown for that particular month.

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10. Who is a principal provider?

A Principal Provider can change from month–to–month per individual. A Principal Provider may be a Managed Long Term Care Plan (MLTC), a medical provider, an Assisted Living Program, or a Skilled Nursing Facility/Nursing Home/Residential Healthcare Facility.

An individual may have an MLTC plan that has a monthly premium; this may be used to satisfy a monthly spenddown if it equals or exceeds the monthly spenddown amount. An individual may have an unpaid inpatient hospital bill which may be used to meet his/her spenddown if the amount of the bill equals or exceeds six times the monthly spenddown amount. The Principal Provider would be the hospital.

If an individual is in an Assisted Living Program, or a Nursing Home/ Skilled Nursing Facility/ Residential Healthcare Facility, the program or facility will appear as the principal provider. Individuals in the aforementioned programs or facilities will have recipient restriction/exemption codes of AL or NH respectively and will not be eligible to be a member of a Health Home.

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11. For individuals who meet their spenddown monthly by submitting proof each month, can Health Homes bill?

Yes, Medicaid coverage begins on the first day of the month. Once compatible Medicaid coverage is authorized for a given month, a Health Home can submit a claim as long as a core service was provided.

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12. When bills/receipts/payments are submitted timely to satisfy the monthly spenddown, there can be a delay in updating the coverage from provisional to outpatient or inpatient (depending on what type of bill was submitted). Is there a policy to support how long (days) a district has to update the coverage?

When the monthly spenddown is met, regardless what day of the month it is met, the coverage begins on the first day of the month. Care Management providers bill for claims on the first of the month. If care management services were provided for that month, and the individual became eligible for inpatient/outpatient coverage later in the month, the agency would still be able to submit the claim.

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13. How does spenddown work with US residents versus non US residents?

The Spenddown program does not work differently for US residents vs. non US residents. Medicaid coverage may be different when a spenddown is met. When working with members that have a spenddown please ensure that the member has Medicaid coverage that is compatible with the Health Home Program. Click here for information on coverage codes and Health Home Services.

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14. What entity would be the principal provider for the spenddown if the Health Home member is also serviced by an MLTC?

The individual´s monthly spenddown is applied to the MLTC premium. MLTC rates are constructed with that consideration.

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