WAG 15-08-10: Starting Medical Coverage

PM 15-08-10

1. (FCRC or Pay-in Unit) Enters all bills/receipts and payments into IES. Enter the month in which medical benefits are requested in the Circumstance Start/Change/Date.  Enter information within 2 workdays of receipt of the medical expenses or payments.
2. (System) IES will run eligibility to meet spenddown based on the Circumstance Start/Change/Date.
3. (System) Updates eligibility in MMIS.

(FCRC or Pay-in Unit) Update the IRDB (see WAG 22-08-18) if the client reports a need for medical services before the eligibility update is posted to MMIS.

Update the IRDB no later than the end of the 2nd workday following the day of the request.

Example: If the client reports a medical need on Wednesday, update the IRDB no later than Friday of the same week.

Monthly Spenddown Met

1. (System)  IES will automatically run eligibility each month to determine ongoing eligibility.
2. (FCRC or Pay-in Spenddown Unit) Immediately determine whether spenddown is met when the FCRC or Pay-in Spenddown Unit receives medical bills/receipts or payment report.

   The determination should be made in IES within 2 workdays of the day the bills were received in the FCRC or within 2 workdays of the day the Pay-in Spenddown Unit receives the payment report.

3. (System) Whenever spenddown is met by IES, the system will automatically update.  If the case is enrolled in Pay-in Spenddown, it will be updated as well (see WAG 15-08-15-b).
4. (FCRC) Manually mail Form 2432 to the vendors within 14 calendar days of the receipt of the bills which caused spenddown to be met.
   1. Mail original to provider.
   2. File a copy in the case record.
5. (System) Prints Split Billing Transmittal for MANG (Form 2432C) when a spenddown met is processed.
6. (FCRC) Make and distribute any additional required copies of Form 2432C.
   1. Mail original to provider.
   2. File a copy in the case record.

Monthly Spenddown Met Through Carryover

(System)  IES automatically run eligibility monthly. Spenddown will be met if bill/receipts and payment are sufficient to meet spenddown. 

(System) Takes action, after cut-off and generates Notice of End Eligibility for Medical benefits (Form 3358) to the client. The notice says that medical coverage will be ending.

• Changes the spenddown status to Unmet.
• Stops medical eligibility.

Do not exceed 6 months from the month in which the action is being submitted, which will prevent the central action from taking place.

Monthly Spenddown Met by SMIB and/or Medical Insurance Premium Deductions

1. (FCRC) Go to Medical Expense Details page select and select the following:

2. (IES) Determine spenddown met in IES for up to 6 calendar months from the month the action is being processed. 
3. (IES) Sends Form 360C to notify the client of the spenddown met determination.