WAG 15-08-15-c

HFS identifies clients who are entitled to Pay-in refunds and issues refunds. Refunds will always be made to the client or the client's estate whether or not someone else made the original payment on their behalf.

A Client may be entitled to a refund of a Pay-in payment if:

  • their case was canceled or no longer in spenddown status in the month(s) for which they paid,
  • they have an unused payment carryover on a canceled or non-spenddown case,
  • the cost of the medical services paid by HFS for a month is less then the amount of the payment they made on an income spenddown for that same month, or
  • the cost of the total medical services paid by HFS is less then the amount of the payment they made on an asset spenddown. (Note: A refund of an asset spenddown payment can be made only after the HFS medical case has been canceled at least 16 months.)

Refunds on Non-Spenddown and Canceled Cases (Payment was not used to meet spenddown)

Two reports are generated and sent to the Pay-in Spenddown Unit:

  1. A daily report identifies active cases that are no longer in spenddown status that must be reviewed to determine if a refund is due.
  2. A monthly report identifies cases that have an unused Pay-in payment carryover and have been canceled for 90 days.

Upon receipt of these reports, Pay-in Spenddown Unit staff determine whether a refund is due, and if appropriate, issue a refund to the client using the C13 process (see WAG 26-04-01: C-13 Invoice Voucher).

Reconciliation Refunds on Payments Used to Meet Spenddown

Reconciliation reviews are conducted for clients who have been enrolled in the Pay-in option for 15 months or longer. HFS identifies clients who are entitled to a refund and issues refund payments once per quarter.

Two types of reviews are used:

  • Automated reviews are used for most income spenddown cases.
  • Manual reviews are completed by the Pay-in Spenddown Unit for cases in which payments were made to meet an asset spenddown or when a companion case was identified (Item 80 contained code 385 or 386).

Income Spenddown Paid-in - Clients who paid-in to meet their income spenddown obligation may be entitled to a refund. If the amount they paid for a particular month is greater than the claims paid on their behalf for that month, a refund will be issued. To allow enough time for providers to submit claims, refunds will be made no sooner than 16 to 18 months after the month service was provided to the client.

Asset Spenddown Paid-in - Clients who paid-in an asset spenddown obligation may be entitled to a refund when their paid-in asset spenddown obligation is greater than their total amount of medical claims. Refunds on payments used to meet an asset spenddown obligation will be made no sooner than 16 to 18 months after the medical case has been canceled.

Both Income and Asset spenddown Paid-in - When the client paid-in both an asset and an income spenddown, HFS must first reconcile the amount paid-in to meet the asset spenddown. The asset spenddown payment is reconciled when the total medical claims paid by HFS meet or exceed the amount paid toward the asset spenddown. An asset refund will not be due.

Next, HFS determines if an income spenddown payment refund is due for the reconciliation month by comparing the amount of claims paid that exceed the asset spenddown to the cumulative income spenddown payments made.

Once the asset and income spenddown payments to date have been reconciled, the Item 80 code 386 will be removed and the case will no longer be tagged for a manual review.