D.C. Mun. Regs. tit. 29, r. 29-9516

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-9516 - SPEND DOWN FOR MEDICALLY NEEDY COVERAGE

9516.1

This section establishes the calculation of spend down and eligibility determination process for medically needy individuals who have income above the income limit for their respective eligibility coverage group, pursuant to the requirements set forth under 42 CFR § 435.831.

9516.2

The spend down process shall not apply to individuals that have resources above the resource limit for their respective eligibility coverage group.

9516.3

Individuals in eligibility groups described in Subsections 9515.3 through 9515.4 with household incomes that exceed the income limit but otherwise meet the eligibility requirements for their coverage group shall submit qualifying incurred medical and remedial expenses in order to qualify for medically needy coverage through spend down. The individual shall submit expenses that may be used as follows:

(a) To fulfill the individual's spend down obligation during a retroactive budget period or prospective budget period, as described in Subsections 9516.8 and 9516.13; or

(b) To be carried forward to fulfill a spend down obligation in a future budget period if any unpaid amount submitted for a previous budget period was unused, subject to the requirements set forth under Subsections 9516.15.

9516.4

The Department shall use budget periods in accordance with Subsection 9516.6 to compute the spend down obligation that an individual must meet in order to be eligible for medically needy Medicaid through spend down. Except for computing the spend down obligation(s) for retroactive medically needy Medicaid coverage as described in Subsections 9516.5 and 9516.8, the initial budget period begins on the first day of the first month an individual applies for Medicaid.

9516.5

An individual may request a separate budget period for retroactive medically needy coverage through spend down for up to three (3) calendar months immediately before the month of application, subject to the requirements set forth under Subsection 9516.8.

9516.6

The Department shall use the following budget periods for individuals who have been determined eligible for medically needy coverage through spend down:

(a) For eligibility groups described in Subsections 9515.3 and 9515.4 who are not applying for or receiving long term care services and supports, the Department shall use a one (1) month period to budget the individual's spend down obligation; and

(b) For the eligibility groups described in Subsection 9515.4 who are applying for or receiving long term care services and supports, the Department shall use a six (6) month period to budget the individual's spend down obligation.

9516.7

The Department shall use the following process to calculate the spend down obligation for medically needy coverage for an individual who meets one (1) of the eligibility groups under Subsections 9515.3 and 9515.4:

(a) Determine countable income by subtracting allowable deductions from the applicant's or beneficiary's gross income, as appropriate, as follows:

(1) For eligibility groups under Subsection 9515.3, subtract allowable deductions in accordance with Section 9506 of this chapter and 42 CFR § 435.831(b)(1)(ii); and

(2) For eligibility groups under Subsection 9515.4, subtract allowable deductions in accordance with the requirements set forth in Section 9511 of this chapter and 42 CFR § 435.831(b)(2); or

(b) Determine the dollar amount of the medically needy income limit (MNIL), as described in Supplement 8a to Attachment 2.6-A, page 2 of the Medicaid State Plan (also found at: https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DHCFStatePlanAttach2-6aSup8a.pdf ), that applies to the applicant's or beneficiary's household size for each month of the budget period as follows:

(1) The MNIL for a household of two (2) or more individuals shall be fifty percent (50%) of the annual Federal Poverty Level (FPL); and

(2) The MNIL for a household of one (1) shall be ninety five percent (95%) of the MNIL for a household of two (2).;

(c) Verify that the applicant's or beneficiary's countable income, as determined under Section 9516.7(a), exceeds the Medically Needy Income Level (MNIL) in accordance with the methodology described in 42 C.F.R. §§ 435.831(b)(1)(ii) or (b)(2);

(d) Calculate the applicant's or beneficiary's spend down obligation as follows:

(1) For individuals using a one (1) month budget period:

Countable income - MNIL = Individual's spend down obligation for the one (1) month budget period; and

(2) For individuals using a six (6) month budget period:

(Countable income - MNIL) × 6 = Individual's spend down obligation for the six (6) month budget period; and

(e) Use documentation of qualifying medical or remedial expenses to determine whether the documented expenses meet the conditions of a qualifying medical or remedial expense pursuant to the requirements set forth in Subsections 9516.10 and 9516.12.

9516.8

If an individual requests retroactive Medicaid coverage pursuant to Subsection 9516.5, the Department shall calculate the retroactive budget period, which shall be considered separately from the prospective budget period, as follows:

(a) Determine the individual's countable income, consistent with the process described in Subsection 9516.7(a). The Department shall only consider the income available to the individual in the month(s) that the individual requests retroactive coverage;

(b) Determine the individual's MNIL using the process described in Subsection 9516.7(b). The Department shall base the MNIL on the month(s) requested for retroactive coverage;

(c) Verify that the applicant's or beneficiary's countable income exceeds the MNIL in accordance with the methodology described in 42 CFR §§ 435.831(b)(1)(ii) or (b)(2);

(d) If the requested months of retroactive coverage are consecutive, the individual shall have a choice to either:

(1) Consider each month of retroactive coverage separately to determine a spend down amount for each month using the calculation described in Subsection 9516.7(d)(1); or

(2) Combine the excess income for each month to obtain one (1) spend down amount for the retroactive period using the calculation described in Subsection 9516.7(d)(1). For example, if an individual requests retroactive coverage for two (2) consecutive months and chooses to combine the excess income for each month, the calculation shall be as follows:

(Countable income for month one (1) - MNIL) + (countable income for month two (2) - MNIL) = Individual's spend down obligation for the two (2) month retroactive period;

(e) If the requested months of retroactive coverage are not consecutive, consider each month separately and determine a spend down amount for each month using the calculation described in Subsection 9516.7(d)(1); and

(f) The individual shall have a choice to apply a specific qualifying incurred medical or remedial expense towards a spend down amount for a retroactive budget period, prospective budget period, or both, as long as the expense meets the requirement in Subsection 9516.10(d).

9516.9

The Department shall deduct the following types of qualifying incurred medical or remedial expenses that meet the requirements of Subsections 9516.10 and 9516.12, once the spend down amount is determined:

(a) Medicare and other health insurance deductibles, coinsurance charges, enrollment fees, copayments and premiums;

(b) Medical or remedial expenses for necessary medical or remedial services not included in the Medicaid State Plan or HCBS Waivers;

(c) Medical or remedial expenses for necessary medical or remedial services included in the Medicaid State Plan or HCBS Waivers, which exceed the Department's limitations on amount, duration, or scope of services, as described in Section 3 of the District's Medicaid State Plan, Appendix C of the HCBS Waivers, and corresponding rules; and

(d) Medical or remedial expenses for necessary medical or remedial services included in the Medicaid State Plan or HCBS Waivers which are within the Department's limitations on amount, duration, or scope of services, as described in Section 3 of the District's Medicaid State Plan, Appendix C of the HCBS Waivers, and corresponding rules.

9516.10

To be determined a qualifying incurred medical expense, an expense shall meet the following requirements:

(a) Be a necessary cost incurred by an individual for medical goods or services that meets one (1) of the types of expenses outlined in Subsections 9516.9(a)-(d), and may include, the following types of medical goods and services:

(1) Inpatient hospital services;

(2) Outpatient hospital services;

(3) Laboratory and x-ray services;

(4) Nursing facility services;

(5) Physician services;

(6) Clinic services;

(7) Dental services;

(8) Rehabilitation services;

(9) Durable Medical Equipment (DME); and

(10) Home health services;

(b) Be an incurred expense for which the individual, the individual's family, or the individual's financially responsible relatives, as described in 42 CFR § 436.602, is financially liable;

(c) Not be subject to payment by a third party unless the third party is a State or territory's public program financed by the State or territory, other than the Medicaid program;

(d) Not already be used to meet a spend down obligation for a previous budget period, unless an unused and unpaid portion of an expense is being carried forward consistent with Subsection 9516.3(b); and

(e) Be verified by a prescription, referral, bill, receipt, or written statement regarding the goods or services provided, or through other means of documentation required in DHCF policy.

9516.11

Only applicants and beneficiaries of institutional services described in Subsection 9515.4(a) may use medical institutional expenses (other than expenses in acute care facilities) projected to the end of the budget period at the Medicaid reimbursement rate to meet their spend down obligation, subject to the following conditions:

(a) Only medical expenses that are not subject to payment by a third party may be counted;

(b) Medical expenses shall include expenses that the individual or family or financially responsible relatives, as described in 42 CFR § 436.602, are projected to incur within the six (6) month budget period;

(c) Only medical expenses related to institutional care may be projected; and

(d) Projected medical institutional expenses applied towards an individual's spend down obligation shall be subject to the six (6) month periodic reconciliation of expenses to determine whether spend down was met in accordance with 42 CFR § 435.831(i)(2).

9516.12

To be determined a qualifying incurred remedial expense, an expense shall meet the following requirements:

(a) Be a nonmedical support service cost, that does not pertain, relate, or belong to the study and practice of medicine, or the science and art of the investigation, prevention, cure, and alleviation of disease;

(b) Be a cost that is made necessary by the individual's medical or functional condition and that is directly related to the individual's medical or functional care;

(c) Be a necessary cost for a good or service, consistent with the descriptions in subparagraphs (a)-(b) of this subsection, that meets one (1) of the types of expenses outlined in Subsections 9516.9(a)-(d), and may include, but not be limited to:

(1) Travel costs incurred in order to obtain medical services or supplies; and

(2) Home or vehicle modifications that provide a direct medical or functional benefit and is necessary due to the individual's medical or functional condition;

(d) Be an incurred expense for which the individual, the individual's family, or the individual's financially responsible relatives, as described in 42 CFR § 436.602, is financially liable;

(e) Not be subject to payment by a third party unless the third party is a State or territory's public program financed by the State or territory, other than the Medicaid program;

(f) Not have been used to meet a spend down obligation for a previous budget period, unless Subsection 9516.3(b) applies; and

(g) Be verified by a prescription, referral, bill, receipt, or written statement regarding the goods or services provided, or through other means documented in DHCF policy.

9516.13

Pursuant to 42 CFR § 435.831(f), the Department shall deduct incurred medical and remedial expenses that have not been previously applied in establishing eligibility, based on age of bills as follows:

(a) For the retroactive budget period, paid or unpaid expenses incurred during such period;

(b) For the first prospective budget period that also includes any of the three (3) preceding months, paid or unpaid expenses incurred during such period;

(c) For the first prospective budget period that does not include any of the months preceding the month of application, paid or unpaid expenses incurred during such budget period and any of the three (3) preceding months;

(d) For any of the three (3) months preceding the month of application that are not includable under Subparagraph (b) of this subsection, expenses incurred in the three (3) month period that were a current liability of the individual in any such month for which a spend down calculation is made;

(e) Current payments made in the current budget period on other expenses incurred before the beginning of the budget period; and

(f) If the individual's eligibility for medical assistance was established in each such preceding period, expenses incurred before the current budget period, to the extent that such expenses are unpaid and are:

(1) Described in Subsection 9516.9; and

(2) Carried over from the preceding budget period or periods because the individual had a spend down obligation in each such preceding period that was met without deducting all such incurred, unpaid expenses.

9516.14

Pursuant to 42 CFR § 435.831(h)(2), the Department shall deduct incurred medical and remedial expenses in chronological order by the date each service is furnished, or in the case of insurance premiums, coinsurance or deductible charges, the date such amounts are due. Expenses for services furnished on the same day shall be deducted in the following order:

(a) Medical or remedial care expenses for necessary medical or remedial care not included in the Medicaid State Plan;

(b) Medical or remedial care expenses for necessary medical or remedial care included in the Medicaid State Plan, which exceed the Department's limitations on amount, duration, or scope of services; and

(c) Medical or remedial care expenses for necessary medical or remedial care included in the Medicaid State Plan, which are within the Department's limitations on amount, duration, or scope of services.

9516.15

The Department shall not apply medical and remedial expenses towards an individual's initial spend down obligation if the expenses were incurred more than three (3) months before the month of application, subject to Subsection 9516.13(e).

9516.16

Once the applicant has submitted medical and remedial expenses to the Department to meet the spend down obligation and has met all other Medicaid eligibility factors, as appropriate, the Department shall make an eligibility determination and provide notice in accordance with Subsection 9516.24.

9516.17

For individuals described in Subsections 9515.3 and 9515.4, the Department shall determine the start of the eligibility period as follows:

(a) If the individual's spend down obligation is met on a date within the budget period, eligibility shall begin on the date the spend down obligation is met (which shall be the latest date of service of an expense submitted and approved to meet the spend down obligation for that budget period) and end on the last day of the individual's budget period, unless Subsection 9516.18 applies; and

(b) If the individual's spend down obligation is met using only expenses for services received on a date prior to the budget period, eligibility shall begin on the first day of the first month of the budget period and end on the last day of the individual's budget period.

9516.18

For individuals who are required to contribute a portion of income towards the costs of institutional care or HCBS Waiver services pursuant to the requirements set forth under Section 9804 of Title 29 of the District of Columbia Municipal Regulations, the eligibility start date shall be the first day of the budget period if:

(a) The individual's spend down obligation is met after the first day of the budget period; and

(b) Beginning eligibility after the first day of the budget period makes the individual's share of health care expenses under the post eligibility treatment of income rules, as determined under Section 9804 of Title 29 DCMR, greater than the individual has in contributable income.

9516.19

Pursuant to 42 CFR § 435.831(i)(5), expenses used to meet a spend down obligation shall not be reimbursed under Medicaid.

9516.20

In order to obtain Medicaid reimbursement for any remaining portion of an expense that was not used to meet a previous spend down, the expense shall meet the applicable requirements set forth under the District's Medicaid State Plan and applicable laws and regulations.

9516.21

For beneficiaries using a six (6) month budget period, if the individual meets his or her spend down obligation for the first budget period and becomes eligible for medically needy Medicaid, the following shall occur:

(a) The Department shall automatically determine that the beneficiary is eligible to qualify for medically needy Medicaid by meeting spend down in accordance with Subsection 9516.7 for a second six (6) month budget period;

(b) The Department shall send a notice that otherwise complies with Section 9508 to the beneficiary sixty (60) days in advance of the end of the first budget period to inform the beneficiary that the beneficiary's medically needy Medicaid eligibility will expire at the end of the current budget period, and the individual must inform the Department of any changes in circumstances that would affect his or her Medicaid eligibility. The Department may also include additional information in the notice as follows:

(1) The beginning and ending dates of his or her next budget period;

(2) The amount of his or her spend down obligation for the next budget period; and

(3) Notice that the individual must submit sufficient qualifying incurred medical and remedial expenses to meet spend down for the next budget period before he or she will regain medically needy Medicaid eligibility.

9516.22

Upon renewal, the Department shall calculate an individual's six (6) month spend down obligation in accordance with the methodology described in Subsection 9516.7, and shall take into account any submitted but unused expenses that can be carried over from a previous budget period, if applicable.

9516.23

For continued medically needy Medicaid coverage through spend down, the following shall occur:

(a) For beneficiaries with a six (6) month budget period:

(1) The Department shall send the beneficiary a notice consistent with Subsection 9516.21(b); and

(2) The Department shall send the beneficiary a renewal form for the beneficiary's completion no later than ninety (90) days prior to the end of the beneficiary's twelfth (12th) month of Medicaid eligibility, as long as the beneficiary has met his or her spend down obligation for both six (6) month budget periods; and

(b) For beneficiaries with a one (1) month budget period, the beneficiary shall continue to meet his or her spend down obligation for each budget period. By the twelfth (12th) month following the first prospective budget period, the beneficiary shall submit a new application to the Department, consistent with Subsection 9515.7, in order for the Department to redetermine the beneficiary's Medicaid eligibility.

9516.24

The Department shall provide timely and adequate notice of eligibility and enrollment determinations and the right to appeal to applicants and beneficiaries consistent with the requirements set forth in Section 9508, 42 CFR § 435.917 and other applicable rules.

9516.25

The Department may include additional information in the notice described in Subsection 9516.24 that is not required under federal or District law, which may include but is not limited to the following:

(a) The beginning and end dates of the individual's budget period, as described in Subsection 9516.6;

(b) The beginning and end dates of the individual's eligibility period, which shall be the time period during which spend down has been met (consistent with the requirements set forth under Subsection 9516.17) and the individual is fully eligible for Medicaid;

(c) The individual's spend down obligation, as determined in accordance with Subsection 9516.7, for the individual's corresponding budget period;

(d) Instructions for submitting documentation of expenses consistent with the requirements set forth under Subsections 9516.10(e) and 9516.12(g);

(e) Instructions that the individual may submit documentation for a twelve (12) month period;

(f) The total amount of the acceptable qualifying incurred medical and remedial expenses that the individual has already submitted, if any;

(g) Description of expenses that were submitted but are not acceptable towards the individual's spend down obligation;

(h) An explanation of why any documentation was not acceptable pursuant to the requirements of Subsections 9516.10 and 9516.12, if applicable;

(i) The remaining amount of incurred medical and remedial expenses that is required to meet the individual's spend down obligation; and

(j) The amount of unpaid expenses that may be carried over towards the next budget period.

D.C. Mun. Regs. tit. 29, r. 29-9516

Final Rulemaking published at 69 DCR 12069 (10/7/2022)