405 IAC 2-3-10 - Spend-down eligibility
Authority: IC 12-13-5-3; IC 12-13-7-3; IC 12-15-1-10
Affected: IC 12-15-4; IC 12-15-5
Sec. 10.
(a) The
following definitions apply throughout this section:
(1) "County office" means the county office
of the division of family resources of the family and social services
administration.
(2) "Incurred
medical expenses" has the meaning set forth in
42
CFR 435.121(f) and
subsection (e). The term includes expenses incurred by the applicant's or
recipient's spouse or parent whose income is counted in determining the
applicant's or recipient's eligibility for Medicaid. The term does not include
expenses that are subject to payment or have been paid by a third party, except
expenses paid by the following:
(A) A state
program.
(B) A local
program.
(C) Discounts or
assistance received under the Medicare drug discount card and transitional
assistance program authorized under
42
U.S.C. 1395w-141.
(3) "Spend-down obligation" means the amount
of any excess monthly income remaining in the eligibility determination in
section 20(a)(14) of this rule.
(b) In order to be enrolled in Medicaid under
the spend-down provision, an otherwise eligible applicant must provide
documentation to the county office of incurred medical expenses in excess of
the spend-down obligation. If the applicant's ongoing incurred medical expenses
do not exceed his or her excess income, his or her application will be denied.
Medicaid coverage will be approved for any month prior to the denial date in
which incurred medical expenses equaled or exceeded the spend-down obligation,
if all other eligibility requirements are met for the month. The Medicaid
program will reimburse covered services in accordance with 405 IAC 5 for
incurred medical expenses in excess of the spend-down obligation.
(c) Incurred medical expenses will credit the
spend-down obligation in the following order and manner:
(1) Incurred medical expenses submitted to
the county office as described in subsections (e) and (f).
(2) Medicaid copayments beginning with the
month the service requiring the copayment was incurred and continuing in
subsequent months until the full copayment has credited the spend-down
obligation.
(3) Medicaid claims
filed by Medicaid providers in accordance with
405
IAC 1-1-3.1.
(d) Claims submitted by Medicaid
participating providers for services rendered to enrolled Medicaid recipients
will credit the recipient's spend-down obligation in the month of the service
and in the order of submission. A service that is not payable by the Medicaid
program under 405 IAC 5 will not credit the spend-down obligation, except for a
service that is not covered for the following reasons:
(1) The service is subject to a benefit
limit; and
(2) There is no
provision for obtaining prior authorization for coverage for services that
exceed the benefit limit.
Any amount paid or payable by a third party will not credit the spend-down obligation. The amount owed by the recipient after the third party has adjudicated the claim will credit the spend-down.
(e) Incurred medical expenses for
services for which claims cannot be submitted directly by Medicaid providers
must be submitted to the county office for the purpose of crediting the
spend-down obligation. The documentation of an expense submitted to the county
office must be a bill, a receipt, or other documentation of the individual's
liability for the expense. The following are examples of expenses that must be
submitted to the county office:
(1) Expenses
incurred before the individual was eligible for Medicaid.
(2) Expenses incurred by the recipient's
spouse or other person whose income is considered in determining the
recipient's eligibility.
(3)
Expenses incurred for services provided by a non-Medicaid provider.
(f) For expenses submitted to the
county office under subsection (e), the spend-down obligation will be credited
for the month following the month of submission to the county office or, at the
request of the recipient, in the month of service or in the month of submission
of the expense to the county office. The incurred medical expense shall credit
spend-down in subsequent months until the entire balance of the expense has
been applied. The following incurred medical expenses will be credited toward
spend-down under this subsection:
(1) Medical
care provided by physicians, psychiatrists, and other licensed medical
practitioners.
(2) Laboratory
testing, x-rays, and other diagnostic procedures.
(3) Dental services provided by a licensed
dentist, including dentures.
(4)
Hospitalization and outpatient treatment.
(5) Nursing facility services and
rehabilitative services.
(6)
Respiratory, occupational, speech, physical, and audiology therapy
services.
(7) Prescription drugs
and over-the-counter medication, including insulin, when prescribed by a
licensed medical practitioner who is authorized to prescribe legend drugs under
Indiana law.
(8) The cost of
postage incurred by the individual for mail order prescriptions.
(9) Medical supplies, if ordered in writing
by a licensed physician or dentist for treatment of a medical condition, except
those items identified as noncovered medical supplies under 405 IAC
5.
(10) Durable medical equipment
if ordered in writing by a licensed physician except those items listed as
noncovered equipment under
405 IAC
5-19-18.
(11) Home health care provided by a licensed
home health agency.
(12) Nursing
services provided by a registered nurse or licensed practical nurse.
(13) Audiology services and hearing aids if
ordered in writing by a physician.
(14) Prosthetic devices other than those
dispensed for purely cosmetic purposes, if ordered in writing by a physician,
optometrist, or dentist.
(15)
Vision care services including eyeglasses, examinations, and diagnostic
procedures.
(16) Cost of
transportation to obtain medical services that are allowable medical expenses.
If transportation is provided by a business transportation carrier, the
verified carrier's charge will be allowed. If the individual or a friend or
family member drives the individual to medical services, mileage cost is
allowed at the rate per mile established by the Indiana legislature for state
employees.
(17) The premium of the
recipient's spouse who receives Medicaid for Employees with Disabilities (MED
Works).
(18) Medicaid copayments
and any copayments required by other health coverage programs or health
insurance carriers.
(19) Premiums
for health and hospitalization insurance policies that limit benefits to the
reimbursement of medical expenses.
(20) Medicare premiums.
Notes
Transferred from the Division of Family and Children ( 470 IAC 9.1-3-12 ) to the Office of the Secretary of Family and Social Services ( 405 IAC 2-3-10 ) by P.L. 9-1991, SECTION 131, effective January 1, 1992.
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