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DDES INFO MEMO 2006-01

STATE OF WISCONSIN
Department of Health and Family Services
Division of Disability and Elder Services

To: Area Administrators / Human Services Area Coordinators
County COP Coordinators
County Department of Community Program Directors
County Departments of Developmental Disabilities Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
County Waiver Coordinators
DDES Bureau Directors
DDES Section Chiefs
Tribal Chairpersons/Human Services Facilitators

From: Sinikka Santala, Administrator

Re: Medicaid Waiver Group C Participants

The purpose of this memo is two-fold:

I. To provide Group C "single" waiver participants with the option for pre-paying the entire monthly spenddown directly to the county. (Group C "single" means unmarried or that spousal impoverishment rules do not apply.)

II. To establish a uniform protocol for processing that portion of a Group C "single" spenddown which is applicable to Medicaid card services.

Background

I. To establish financial eligibility, all Group C waiver applicants or participants must incur enough medical and remedial expenses to reduce their countable income to the medically needy income limit of $591.67 on a monthly basis.

After eligibility is established, Group C "single" participants are financially responsible for their spenddown on a monthly basis. (Group C married, when spousal impoverishment rules apply, may be responsible for a cost-share.)

Currently, care managers ensure that sufficient medical and remedial expenses are incurred monthly by all Group C waiver participants to establish and maintain financial eligibility. Furthermore, care managers track spenddown payments by the Group C "single" waiver participant to various providers of services, because the Group C "single" waiver participant is responsible for the entire spenddown amount.

Now the Group C "single" waiver participant will also have the option of pre-paying the entire spenddown to the county (as described below).

II. In rare cases, the spenddown liability includes Medicaid card covered services. Currently, there is no uniform process for Long Term Support Agencies (LTSA) to credit the appropriate entity with the portion of the spenddown attributable to Medicaid card services cost. The protocol to follow in these cases is explained below.

It is expected that these clarifications will impact approximately 150 Group C "single" waiver participants statewide.

I. New option for pre-paying the entire spenddown to the county's Long Term Support Agency (LTSA)

Effective with the date of this memo, in addition to the current option of paying the spenddown to COP and Medicaid Waiver providers as described above, Group C "single" waiver applicants or participants may also be given the option of pre-paying the entire monthly spenddown directly to the county. The county will then disburse the spenddown as appropriate.

Avoiding overpayments

Prior to accepting the monthly spenddown liability prepayment, the Long Term Support Agency (LTSA) must ensure that the full spenddown will be "incurred." If the spenddown is not incurred, eligibility for the particular month was not established. A notice of termination should be generated as described in DDES Memo Series 2005-18 (dated 10/12/2005). Exception: if it is expected that the Group C waiver participant will incur the entire spenddown the following month, and the reason for not incurring the entire spenddown during the current month is due to exceptional circumstances (e.g., reduced need for waiver services because the participant was absent for a short period), termination will not be necessary. However, it is important to advise the waiver participant that if the spenddown will not be incurred again the subsequent month, termination will follow.

Accepting prepayment for a spenddown which is not going to be incurred in its entirety would also result in an overpayment to the county, and a refund to the Group C waiver participant may be necessary.

II. Uniform protocol for processing the portion of Group C "single" spenddown which is applicable to Medicaid card services.

When the Group C "single" spenddown liability includes Medicaid card costs, the county's fiscal unit will apply the participant's liability as follows:

For individuals age 55 or older

The county's fiscal unit will disburse the payment to the Estate Recovery Program, as a spenddown. The payment should be made payable to DHS and should be mailed to:

Estate Recovery
6406 Bridge Road
Madison, WI 53784-0013

With the payment, include documentation that the payment is for spenddown, the client's name and Medicaid ID number, name and address of the person who should receive the receipt.

The payment will be credited to the waiver participant and will be used to offset any claim that may be filed in the client's estate.

For individuals under age 55

The payment for the spenddown will be made to the county and the county will report receipt on the Community Aids Reporting System (CARS), on line 909.

REGIONAL OFFICE CONTACT: OSF/Human Services Area Coordinators

CENTRAL OFFICE CONTACTS: Rita Cairns
COP/COP-W and CIP-II Financial Eligibility Specialist
Bureau of Long-Term Support
1 W. Wilson St., Room 450
P.O. Box 7851
Madison, WI 53707-7851
Phone: (608) 266 6891
Fax: 608-267-2913
E-mail: cairnri@wisconsin.gov

MEMO WEB SITE: http://www.dhs.wisconsin.gov/partners/local.htm

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Last Revised: January 29, 2014