WAG 15-08-11.

If the medical expense that met spenddown meets the following criteria, it is a split bill. The bill is a split bill if it:

  • is an unpaid bill for an amount greater than the amount needed to meet spenddown, and
  • was incurred in the month that the spenddown determination is being made, and
  • is for a Medicaid covered service, and
  • the client wants to use the bill for the month of service.

The bill is processed as a split bill, and the client is responsible for the spenddown portion of the split bill and any other bills used to meet spenddown for that month. Report as a split bill, with no client liability, any other bills for a covered service that were incurred on spenddown met day and were not used to meet spenddown.

If one of the following bills is used to meet spenddown it is not a split bill:

  • a paid bill, or
  • a bill for a service provided in a month the client was not enrolled in spenddown, or
  • a bill that was incurred on a day other than a spenddown met day, or
  • a bill that the client wants to use to meet spenddown for a month other than the month of service, or
  • a bill that the provider indicates will not be billed to Medicaid, or
  • a bill that is being carried over, or
  • a bill for an uncovered service, or
  • a bill for a DORS HSP service, or
  • a bill for DMHDD Community Based Services (AABD Only).

When the split bill is for a covered service provided by a Medicaid enrolled vendor, HFS centrally determines if Medicaid will pay any part of the bill. If Medicaid is responsible for any or all of the bill, Medicaid pays the part of the bill in excess of the amount needed to meet spenddown at the Medicaid rate.

When hospital costs meet spenddown on the first day of a month, a split bill is required. Medicaid pays the part of the bill in excess of the amount needed to meet spenddown at the Medicaid rate. Complete a split bill for the first day of each month that a hospital stay extends beyond the month of admission.