WAG 15-03-00.
Use the following special definitions when determining medical eligibility and spenddown.
- Adjudicated Bill
An adjudicated bill is a medical bill for which a third party liability (TPL) exists, e.g. health insurance, and for which the amount the third party will pay has been determined.
- Beginning Medical Eligibility Date
The beginning medical eligibility date is the first day that medical eligibility exists.
- For regular medical cases, the beginning medical eligibility date is the first day of the month that medical assistance is authorized.
- For spenddown cases, both community and long term care, the beginning medical eligibility date is the date each month that monthly spenddown is met.
- Bill
A bill is the provider's statement of charges for medical services or supplies, or for medical related expenses such as insurance premiums or transportation to medical care. A bill is also a collection notice, from a collection agent, for payment of
medical services or supplies.
- Billing Date
- Billing date is the calendar date that a bill or collection notice was prepared. This date can be the date of service or a later date. The date must be shown on the bill. If a client has been billed more than once for the same service use the most
recent bill date as the billing date.
- Carryover
Carryover is the part of a bill or receipt not used to meet monthly spenddown. It can be used to meet a later spenddown.
Only the following bills and receipts can be carried over:
- a bill for a service not covered by Medicaid;
- a bill not used in its entirety to meet spenddown for the month of service;
- a bill that a vendor does not bill to Medicaid;
- a bill that is over 12 months old;
- any bill that a client in unmet spenddown status wants to use in a later month;
- a bill where the Medicaid rate is less than the amount needed to meet spenddown, but the private pay rate is greater; or
- any bill that a client owes to a person who is not a legally responsible relative who paid a medical expense for the client, and who wants to be repaid.
- Countable Monthly Income
Countable monthly income is monthly nonexempt income minus allowable deductions.
- Current Bill
A current bill is one that is unpaid and has a billing date that is 6 calendar months or less from the calendar month to which the client wants to apply the bill.
- Enrollment
Enrollment applies to spenddown only. Enrollment means that a person meets all nonfinancial eligibility factors for medical, but countable income exceeds the Income Standard for the case and/or nonexempt assets exceed the asset limit for the
case.
- Long Term Care Credit (AABD)
The long term care (LTC) credit (also called the group care credit) is the amount the client is responsible for paying for their LTC costs. It is the sum of the client's countable monthly income and excess nonexempt assets.
- Long Term Care Charge (AABD)
An LTC charge is a bill or receipt for basic services provided by an LTC facility.
- Medical Services Recognized Under State Law
Medical services recognized under state law, are those services or items provided or ordered by a person or institution licensed or registered with the State of Illinois to provide them.
- Old Bill
An old bill is one with a billing date that is more than 6 calendar months from the calendar month that the client wants to apply the bill to meet spenddown.
- Receipt
A receipt is a written statement of payment for a medical service or supply. To be credited toward spenddown or applied to the long term care credit, the date of payment must be within 6 calendar months of the calendar month that the client wants to
use the bill.
- Service Date
The service date is the specific date that the medical service was received. This date is the date charges are incurred.
- Spenddown Met Day
Spenddown met day is the day that an enrolled case meets spenddown, and becomes eligible for payment of covered medical services. Spenddown met day is the beginning medical eligibility date for that month.
- Split Bill
A split bill is the medical expense that meets spenddown, and:
- is an unpaid bill for an amount greater than the amount needed to meet spenddown, and
- was incurred in the month for which 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.
- Supportive Living Facility Credit (AABD)
The supportive living facility (SLF) credit is the amount the client is responsible for paying for their SLF care costs. It is sum of the client's countable monthly income and excess nonexempt assets.
- Supportive Living Facility Charge (AABD)
The SLF charge is a bill or receipt for basic services provided by an SLF facility.
- Unmet Spenddown Status
Unmet spenddown status is when an enrolled client has not incurred enough medical expenses to meet spenddown. A client who is in this status is not eligible for payment for covered medical services.
