Section 405 IAC 2-3-10 - Spend-down eligibilityAuthority: 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:(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.Office ofthe Secretary of Family and Social Services; 405 IAC 2-3-10; filed Mar 1, 1984, 2:31 p.m.: 7 IR 1021, effApr 1, 1984; filed Feb 16, 1993, 5:00p.m.: 16 IR 1785; filed Jul 25, 1995, 5:00 p.m.: 18 IR 3382; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Sep 7, 2004, 5:00 p.m.: 28 IR 178; filed Jul 18, 2005, 1:00 p.m.: 28 IR 3579; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFATransferred 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.