PM 15-08-15-c

Reconciliation Refunds on Payments Used to Meet Spenddown

Example (Income Spenddown Paid-in): Ms. Pebbles pays-in an income spenddown of $100 per month for July, August and September 2009. In December 2010, the case is automatically reconciled. The monthly pay-in amounts are compared to the claims paid for each review month as follows:

Review Months Pay-in Payment Claims paid by HFS for Review Month Refund due
Jul '09 $100 $300 $0
Aug '09 $100 $75 $25
Sep '09 $100 $90 $10
Total = $35

The Pay-in Spenddown Unit sends a refund of $35 to Ms. Pebbles for the quarter of July - September 2009.

Example (Asset Spenddown Paid-in): Mr. Granite has a $500 asset spenddown and no income spenddown. He pays-in $500 for July 2009. Effective August 2009, the case becomes regular (non-spenddown) AABD MANG. Mr. Granite's regular MANG case is canceled effective 12/09. In March 2011, the case appears on a reconciliation report. The Pay-in Spenddown Unit will complete a manual reconciliation. The report indicates that the total medical claims that HFS paid for Mr. Granite for July through December 2009 was $475. Since the total amount of claims paid is less than the asset spenddown amount paid, Mr. Granite is entitled to a $25 refund.

Example (Both Income and Asset spenddown Paid-in):  Mr. Bedrock has been enrolled in Pay-in Spenddown since July 2009. He had a $2,000 asset spenddown and a $200 income spenddown. A manual reconciliation is done by the Pay-in Spenddown Unit in December 2010 with the following information:

Review Months Pay-in Payment Cumulative Income Pay-in Payment Claims paid by HFS for review month Cumulative claims paid Refund due
Jul '09 $2,200 $200 $500 $500 $0
Aug '09 $200 $400 $1,700 $2,200 $200
Sep '09 $200 n/a $50 n/a $150
total = $350

Step 1: Reconcile the asset spenddown payment. The asset spenddown payment can be reconciled for the review month of August 2009 because the cumulative claims paid by the Department ($2,200) met or exceeded the amount paid-in to meet the asset spenddown ($2,000) as of August 2009.  A refund of the asset spenddown payment will not be due.

Step 2: Reconcile the income spenddown payment for the month the asset spenddown payment was reconciled. Subtract the asset spenddown amount from the cumulative claims paid amount ($2,200 - 2,000 = $200). Then compare the difference of $200 to the cumulative paid-in amount of $400. An income payment refund of $200 is due for August because the paid-in amount of $400 exceeds the excess claims paid amount of $200 .

Step 3: A refund of $150 is due for September 2009 since the income spenddown payment of $200 exceeds the $50 claims paid for that month. A total refund of $350 is issued for July - September 2009. Pay-in Spenddown staff delete Item 80 code 386. The case will be reconciled automatically starting with the October - December 2009 review quarter.