This manual release obsoletes policy memo, Applying Department on Aging (DoA) Community Care Program (CCP) Services to Spenddown, dated 12/06/10.
- Effective with the implementation of IES Phase 2, spenddown will be available for determining ongoing eligibility.
- A batch action runs monthly which results in a mass change action that will determine whether spenddown can be met.
- The Integrated Eligibility System (IES) determines if spenddown is met and takes appropriate action for persons receiving DoA services based on an electronic file from Social Security.
- The Medical Expense Summary page displays individual medical expenses and the spenddown history for each bill.
- Clients enrolled in the Pay-in Spenddown option may meet spenddown by paying their spenddown amount to HFS.
- Spenddown status indicators will display in IES on the Eligibility Summary page under the Benefits/SPD column.
- Bills and receipts that are used to meet spenddown are entered on the Medical Expense Details page.
- Eligibility Monthly Spenddown Bypass page allows the caseworker to stop IES from automatically meeting a spenddown for targeted month if requested by the customer.
- IES will centrally budget waiver services at mass change each month to cases enrolled in spenddown based on an electronic file.
- Circumstance/Start Date determines the month spenddown is met.
- Process an override of the spenddown met date to determine the new spenddown met date.
- IES allows the caseworker to target future months for up to 6 months beginning with the current month.
- The central Pay-In Spenddown Unit will continue to manage the Pay-In Spenddown program in the IES system.
- At conversion, medical bills, receipts, and cash will be converted from ASDS to IES for cases enrolled in spenddown.
- Following conversion, companion cases currently in the legacy system must be merged by the caseworker after the cases are converted into IES .
- Form 360C, Notice of Decision will be centrally sent when a change in spenddown occurs.
- Cases enrolled in Pay-In Spenddown program will not automatically cancel for not meeting spenddown.
- Form 2431/2431S, Application for Medical Assistance-Short Form is obsolete.
- Spenddown Processing in IES
- Medical Expense Details Page-Medical Expense Summary
- Spenddown Status Indicators
- Changes During Enrollment
- Meeting Spenddown Centrally with Home and Community Based Waiver Services
- Consolidated Forms
- Split Bills
- Change in Spenddown Met Date
- Recalculation of a Spenddown Met Month
- Selecting Target Months
- Spenddown Bypass
- Spenddown Conversion
- Converting Spenddown Companion Cases
- Caseworker Actions Required After Conversion
- Pay-In Spenddown
- Cases Canceled Due to Not Meeting Spenddown
- MANUAL REVISIONS
- Forms Referenced
Spenddown Processing in IES
IES will automatically run spenddown eligibility, where previously the worker was required to complete an action. This batch action runs monthly (at or around schedule cut-off) which results in a mass change action that will determine whether spenddown can be met. See manual release, Batch Actions and PAL Codes in IES, dated 05/04/16.
IES will use medical expenses according to PM 15-08-08. IES will meet the spenddown if there are sufficient medical expenses or payments in IES to meet.
Currently, Nursing Home (NH) and Supportive Living Program (SLP) cases are excluded from this automatic process.
Medical Expense Details Page-Medical Expense Summary
The Medical Expense Summary page displays individual medical expenses and the spenddown history for each receipt, bill or payment. To view medical expenses go to the Left Navigation Screen and select Data Collection, select Medical Expenses. IES will also show the following:
- spenddown status
- spenddown met date;
- medical expenses used to meet spenddown; and
- medical expenses used as a split bill.
Spenddown Status Indicators
The Spenddown Status Indicators in IES are located on the Eligibility Summary page/Benefits/SPD column on the Eligibility Summary page. The Indicator will display information based on the type of bill that was used to meet spenddown.
||Spenddown Status Indicator
||Met with Split Bill
||Met with Carry-over
||Met with Waiver or DoA Services
||Met SPND for any other scenario
||Met with Pay-In
Codes previously used in ASDS are not valid in IES. See WAG 27-80-02-b.
Changes During Enrollment
A case may change from regular eligibility to spenddown or from spenddown to regular eligibility for AABD community and Family Health Plan cases. These changes may be made by the worker when running eligibility in IES or may be updated through an automatic batch action by IES.
When a change is processed that causes an increase in spenddown the change will be effective for the first regular roll month.
When a change is processed in IES that results in a decrease in spenddown the change will be effective the month the change occurred.
Example 1: Mary reported on 05/10 that her SSA income increased in May. The increase caused her spenddown obligation to be higher. The increased spenddown obligation will be effective for June, which is the first regular roll month. Form 360C is sent centrally to notify the client of a change in the spenddown amount.
Example 2: On 06/20, John reported that his SSA income decreased beginning in May. The decrease in income made him eligible for medical with no spenddown. The change will be effective for May which is month the change occurred. Form 360C is sent centrally to notify the client of a change in the spenddown status.
Example 3: Mary is pregnant and applies for medical benefits on 04/15. She is employed and her income is over the income limit for Moms and Babies. Due to being pregnant she is enrolled in spenddown as a pregnant woman. On 07/01 she reports that she received her last pay on 06/15. Due to the loss of income she is eligible for Moms and Babies (no spenddown) beginning June.
Meeting Spenddown Centrally with Home and Community Based Waiver Services
IES will centrally enter the waiver services on the medical expense page when received through an electronic file. The expenses are considered when IES automatically runs spenddown eligibility at cut-off. When IES determines that waiver services are sufficient to meet spenddown, spenddown will be met at mass change monthly. When IES determines that spenddown is no longer met with waiver services the case will be placed in unmet status at mass change.
The information on the following forms has been consolidated into Form 360C, Notice of Decision:
||Notice of Decision on App for Medical Assistance
||Decision Payment Medicare Premium
||Notice of Decision of Limited Approval on App for Medical Assistance
||Notice of Decision on Application for Medical Assistance MANG LTC/SLF
||Decision Medical Assistance
||Determination of Monthly Spenddown Met/Unmet
||Notice of Determination of Spenddown Met/Unmet Medical LTC Case
||Change Medical Benefits Medical
||Notice of Change-MANG Long Term Care Case
||AABD MANG Computation Sheet - Community Case
||All Kids/FamilyCare and Moms & Babies Computation Sheet
The above forms are not obsolete.
When IES runs eligibility and a split bill month is identified, a soft message will appear on the Eligibility Summary screen for the caseworker to return to the Medical Expenses -Details page to generate HFS 2432, Split Bill Transmittal for Medical Spenddown Program for all medical expenses incurred on the "split bill date".
On the Medical Expenses-Details page a message will appear that instructs the caseworker to "Generate Form 2432, Split Bill Transmittal for Medical Spenddown Program, for each medical bill that is incurred on split bill date. Write in the control number for each form".
Go to the CAF button to verify which medical expenses require a split bill notice (HFS 2432).
The "Generate Split Bill Form" button will only be enabled when the incurred date of the selected medical expense is the same as the split bill met date.
See WAG 15-08-11 for guidance on how to complete HFS 2432.
Change in Spenddown Met Date
A client may submit additional medical expenses for a month in which spenddown has already been met and request that the expenses be used to meet spenddown earlier in the same month. IES will not automatically recalculate the spenddown.
IES will not reuse bills/receipts, and payments to recalculate a met spenddown month. IES will only use unused expenses when a previous met month requires a change in the spenddown met date. In order to recalculate a previous met month the worker must override the original met date. To change a spenddown met date to an earlier day in the month, review any medical expenses that have not been used to meet spenddown. When changing the spenddown met date to an earlier day in the month refer to PM 15-08-12/WAG 15-08-12 for guidance.
Process an override of the original spenddown met date to determine the new spenddown met date. Generate a new HFS 2432, Split Bill Transmittal for Medical Spenddown Program, for the new split bill date if required.
If the expense(s) was paid by the client or was not covered by Medicaid the expense should be deleted and re-added (change from a bill to a receipt) to be used in future spenddown months. This only applies if the earlier bill(s) are enough to meet spenddown.
Recalculation of a Spenddown Met Month
There are situations when a recalculation of a met month is required due to a client's request. An additional split bill notice(s) may or may not be required. Review each individual request to make that determination.
Example 4: Client has a $50 spenddown. Client submitted a medical bill in the amount of $125.00 for services she received on 05/07. Spenddown was met beginning 05/07 and a split bill is sent to the provider showing client liability of $50. On 5/20 a new bill was submitted for services that were provided on 05/02 in the amount of $60.
A new spenddown met day must be determined by overriding the original spenddown met date. To change the spenddown met day complete the following:
- Under Medical Expense Date enter the Circumstance Start Change Date of 05/02.
- Under Expense Details enter $60 in "total amount billed"
- Under Expense Details Enter $0 as Client Liability Amount.
- Under Expense Details Enter $60 in the Manual Reduction Amount field.
- Go to the Eligibility Summary page and click on the Exception Summary tab.
- Run eligibility and certify the results.
- FCRC sends manual Form 458SP-1, Determination of Monthly Spenddown Met/Unmet.
Client's liability for the new bill is "0" since the client met spenddown on 05/02 and the amount of the new bill is enough to meet spenddown on 05/02. IES re-runs eligibility and certifies the case. The original split bill requires no change. Do not send a new split bill.
A 2nd split bill notice is not required in this situation.
Example 5: Client has a $100 spenddown. On 05/20 the client submitted a medical bill in the amount of $200 for services she received on 05/10. The medical bill was processed and spenddown was met effective 05/10. HFS 2432, Split Bill Transmittal for Medical Spenddown Program Notice, was issued to provider indicating client's liability of $100.
A new bill is submitted for services received on 05/01 in the amount of $125.00. A spenddown met day must be determined by overriding the original spenddown met date.
- Under Medical Expense Date enter the new Circumstance Start Date of 05/01.
- Under Expense Details enter $125 in "total amount billed".
- Under Expense Details Enter "0"in the Client liability Amount.
- Under Expense Details enter $125 in the Manual Deduction Amount field.
- Go to the Eligibility Summary page and click on the override tab.
- Run eligibility and certify the results.
- FCRC sends Form 458SP-1, Determination of Monthly Spenddown Met/Unmet.
Client's liability for the new bill is "0" since the client met spenddown on 05/20 and the amount of the new bill is enough to meet spenddown on 05/01. IES re-runs eligibility and certifies the case. The original split bill requires no change. Do not send a new split bill.
Example 6: Client has a $75 spenddown. On 05/07 client submitted two medical bills. One with a service date of 05/05 in the amount of $30 and one with a service date of 05/07 in the amount of $125. Client is responsible for the payment of the bill for services received on 05/05. Client's liability is $45 for the services received on 05/07. Spenddown met with split bill on 05/07.
A new bill is submitted for services received on 05/02 in the amount of $60. Client request a recalculation of spenddown. A new spenddown met/split-bill day must be determined by overriding the original spenddown met date.
- Under Medical Expense Date enter the new Circumstance Start Date of 05/02.
- Under Expense Details enter $60 in Total Amount Billed
- Enter $30 in the Client Liability Amount.
- Enter $30 in the Manual Reduction Amount (Additional Split Bill) field.
- Go to the Eligibility Summary page and select the Exception Summary tab.
- Run eligibility and certify the results.
- FCRC will print locally and send HFS 2432 (Split Bill Notice) to provider indicating client's liability of $30.
The bill for 05/05 will have "0" client liability because it can be paid by HFS. Send a split bill notice to the provider for the new bill indicating a $30 client liability. Do not change the original split bill notice.
Selecting Target Months
IES allows the caseworker to target future months for up to 6 months beginning with the current month. Set the Circumstance Start/Change Date (CS/CD) as the target month. This sets the target date. The caseworker must certify the case after setting the target month(s) in order for the change to process. The mass change will still continue to run every month but will not use expenses that have been targeted for a particular month(s).
IES runs eligibility every month. In order to stop IES from automatically meeting spenddown a bypass option was created. The bypass allows the caseworker to bypass spenddown for a particular month (s). Access the bypass function from the Left Navigation Screen.
- Select Data Collection
- Select Miscellaneous
- Select Spenddown
- Enter a Begin Date and an End Date to authorize the bypass.
If medical expenses are found in the system for any months that are selected for bypass IES will not process spenddown for those targeted months.
If no bypass record is found, IES will attempt to meet spenddown for the first month possible.
At conversion, medical expenses and payments in ASDS dated 02/01/16 or later will be converted to IES which includes:
- all unused bills and receipts (including carry-over amounts);
- Pay-In payments; and
- all expenses and payments used to meet spenddown for 08/16, 09/16 and 10/16.
These medical expenses will be converted as "Medical Only" expenses. The "Client's Liability Amounts" currently displayed in ASDS will be shown as "Total Amount Billed" which is located under the Medical Expense- Details page.
All unused expenses will be available to meet any future months beginning with the first month IES calculates spenddown. Months that have been targeted in ASDS will be reset to unmet for the regular roll month and any future month(s) when converted into IES.
Beginning with the first processing month, after conversion, IES will run eligibility and attempt to meet spenddown monthly.
Converting Spenddown Companion Cases
At conversion, IES will not convert duplicate medical expenses. Medical expenses that have the same bill date and amount will be considered duplicates. IES will match the First Name, Service Date and Total Amount Billed and transfer the medical expense once. It will disregard the duplicate.
When the date of service and amount billed matches, but the carryover differs on the companion case, IES will bring over the higher carryover balance.
Caseworker Actions Required After Conversion
After conversion, when actions are completed on a spenddown case review the case to see if there are any potential companion cases that could be merged with that case, such as a spouse. Review the legacy case write-up which may identify companion cases. Use the Case Merge functionality to merge cases when appropriate.
The month following the month of conversion the caseworker is required to:
- review the resources on the spenddown case to make sure the resources are also applied if there is a spouse who also has a spenddown case.
- required to manually correct the public or private pay rates on Nursing Homes and Supportive Living Program cases.
The central Pay-In Spenddown Unit will continue to manage the Pay-In Spenddown Program. Pay-in Spenddown Enrollment Form, HFS 458SP-4, will automatically be generated and mailed to persons who are eligible to enroll in Pay-In Spenddown.
If the client meets the criteria to enroll in Pay-In and signs and returns the enrollment form to the Pay-In Unit the Pay-In Unit will enroll case in Pay-In Spenddown. To enroll a case in the Pay-In Spenddown Program the Pay-In Spenddown Unit will perform a case change action. Enter date of the date stamp as the Pay-In Spenddown Enrollment Date, run eligibility and certify the case.
IES Pay-In expense options are:
- Pay-in Income
- Pay-in Asset (Resource)
At mass change, the system will check whether spenddown can be met for the current processing month. If so, IES will meet the spenddown.
Note: Pay-In payments for spenddown can only be entered into IES by the Pay-In Spenddown Unit.
Cases Canceled Due to Not Meeting Spenddown
Cases enrolled in Pay-In Spenddown is exempt from auto cancellation for not meeting spenddown. When a customer's spenddown case is canceled due to not meeting spenddown, the person must reapply. Form 2431/2431S, Application for Medical Assistance-Short Form is obsolete. See PM 02-04-00 for ways to apply for medical benefits.
[signed copy on file]
James T. Dimas
Secretary-designate, Illinois Department of Human Services
Felicia F. Norwood
Director, Illinois Department of Healthcare and Family Services