Spend Down Guidelines

February 27, 2012

  1. Eligibility continues to be based on a calendar month.
    It is important to understand that this discussion is relevant only when CHHA services are utilized by the individual to meet a spend down requirement; if an individual "pays in" to the LDSS or uses services other than the CHHA to meet a spend down, it is not applicable to the episodic payment.
  2. Current policy is that the private pay rate must be used to determine whether the spend down has been met.
  3. No billing dates of service for episodic care may be allowed in any calendar month of non-Medicaid eligibility, e.g., if an individual's services begin at the end of the month such that their spend down for the month is not met, they are not eligible for Medicaid in that month, and the individual would pay privately for that month's services. Episodic payment does not apply.
  4. There is flexibility allowed, based on claim from & through dates, to create episodes in a way that allows for situations such as retroactive eligibility or retroactive determination of different episode start dates. If an individual is determined eligible for a retroactive period during which the individual began receiving services, the episode can begin in the past, or be adjusted as needed.
  5. Spend down must be met, consistent with current requirements on a calendar month basis. The interim claim will account for the spend down for the first month. Providers will need to collect the spend down amount each month as is done currently.