WAG 15-08-12: Change in Spenddown Met Day

PM 15-08-12.

(FCRC) When spenddown for the month was reported as met and the client asks for a recalculation of spenddown met day because of a bill(s) that was incurred before spenddown met day, or when spenddown met day must be changed because of an appeal or Family Community Resource Center error, the Recalc SPD Met for the Month New TextIES.

If a new split-bill day is determined, HFS 2432 is needed to pay bills incurred on either the original split-bill day, or the newly determined split-bill day.

Revised textTo recalculate spenddown met day in IES take the following action:

  • Step 1 -Review the spenddown record in IES.
  • Step 2 -Ask the client if payment has been made on:
    • any of the bills used to meet spenddown for the month, or
    • on any other medical bill incurred during the month, or
    • any bill which has not been used previously to meet spenddown.
  • Step 3 -Figure the amount of the spenddown that remained on and was met on the day that had been figured to be spenddown met day.
  • Step 4 -Process the override to recalculate spenddown met day.

    List first the total spenddown for the month.

    From the total monthly spenddown, deduct the total of the paid bills, if any, figured in Step 2. 

  • Step 5 -Deduct the spenddown that remained on the day that had earlier been designated to be spenddown met day.

    The reason for deducting the amount that remained on the day that spenddown was originally met is that doing so avoids the necessity of having the vendor rebill for the part of the original split bill not paid by HFS. 

  • Step 6 -Deduct in chronological order, the medical costs/items as listed on the old HFS 2430ASP.

    Exclude any bills previously used to meet spenddown which the client has paid. (These bills were deducted in Step 4.)

    Insert in this list of deductions, where chronologically appropriate, the amount of the client's part of the adjudicated bill that has caused the recomputation of spenddown met day.

    Deducting the amounts on the new HFS 2430ASP figures if, as a result of including the adjudicated bill, spenddown was met on an earlier day than previously authorized as met. 

  • Step 7 -If spenddown was not met on an earlier date than previously figured, notify the client by HFS 458SP-1.
  • Step 8 -If spenddown was met on an earlier date, send HFS 2958 to EPU requesting that the spenddown met day for the month be changed.
  • Step 9 -Notify the client of the new beginning medical eligibility date by HFS 458SP-1.
  • Step 10-Complete and distribute HFS 2432s, to authorize billing for allowable bills incurred on the new spenddown met day for which HFS may make payment.

Issue HFS 2432(s) within 14 days of the receipt of the bills which cause a new spenddown met day to be determined.

Example: The following is an example of the order for considering medical costs when a bill is adjudicated after spenddown is met.

An unadjudicated bill is incurred on 02/13 and adjudicated on 04/01. The client's responsibility is $200. On 02/15 an old bill of $100 is paid. The client's spenddown of $600 was previously met on 02/20 with the following expenses considered on a HFS 2430ASP:

(OLD) Spenddown
Monthly spenddown -- -- $600
Paid Receipt for January Bill $100 $100 $500
02/10 Dentist 120 220 380
02/14 Radiologist 150 370 230
02/18 Drugs 80 450 150
02/20 Oral Surgeon 280 730 Met

MMIS will show:

03/01/97 99/99/99 2 UNMET
02/20/97 02/28/97 1 MET
02/01/97 02/19/97 2 UNMET

In this example, on 02/20 $150 of unmet spenddown remained and was met by the $280 oral surgeon's bill. 02/20 was the original spenddown met day. In reviewing the client's bills the FCRC learns that the client has paid the $120 dentist bill incurred on 02/10.

Upon receiving verification that the 02/13 hospital bill has been adjudicated and the client's part is $200, complete a 2nd HFS 2430ASP to figure if the $600 spenddown was met earlier than 02/20.

(NEW) Spenddown Expense Accumulated  Expense Unmet
Monthly Spenddown -- -- $600
Subtract Payments on Bills $220 $220 $380
Spenddown Remaining on 02/20 $150 370 230
02/13 Adjudicated Bill 200 570 30
02/14 Radiologist 150 720 Met/$30 Client Liability

After deducting paid receipts, deduct the amount that remained to be met on the day that spenddown was originally met. In this example, $150 remained to be met on 02/20 and was met by the $280 oral surgeon's bill.

This computation shows that because of considering the adjudicated bill, spenddown was met on 02/14, not 02/20. 02/14 is the new spenddown met day. Notify the client of the change by Form 458SP-1. Because 02/14 is the new spenddown met day, complete and send to the radiologist a Form 2432 showing a client obligation of $30.

Submit a TA 55/TAR 95 to change the existing spenddown met day that resulted from the recomputation using the adjudicated bill. Complete Form 1411 for the client to present to the provider of the drugs (02/18) so that billing can be made. A Form 2432 is not required for the $80 drug bill, as the date of service is now after the new spenddown met day.

MMIS will show:

03/01/97 99/99/99 2 UNMET
02/20/97 02/28/97 1 MET
02/14/97 02/19/97 1 MET
02/01/97 02/13/97 2 UNMET

If a bill is presented during or after the enrollment period has expired, follow the instructions above to figure the new spenddown met day.