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DLTC Memo Series 2008-02

Date: January 23, 2008

To: Listserv

For: Area Administrators / Human Services Area Coordinators-LTC
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
DLTC Bureau Directors
DLTC Section Chiefs
Tribal Chairpersons/Human Services Facilitators
Family Care Managed Care Organizations/WPP
Aging and Disability Resource Centers
From: Sinikka Santala
Administrator

Subject: Medical/Remedial Expenses used for Long-Term Care Medicaid Eligibility and Cost-Sharing

Document Summary

Effective immediately, certain types of medical/remedial expenses will not be allowed when determining cost-shares or spenddowns for people participating in Family Care, Partnership and Home and Community Based Waiver programs

Background

Federal law permits states to impose reasonable limits on allowable amounts of medical/remedial expenses, so long as these limits are described in the Medicaid State Plan and are approved by the Center for Medicaid and Medicare Services (CMS). The Bureau of Eligibility Management (BEM) has amended the State Plan to reflect changes in this regard. OPS Memo #08-02, dated 01/04/2008 was issued to inform Income Maintenance Agencies of the new policy at http://www.dhs.wisconsin.gov/em/ops-memos/2008/default.htm.

This DLTC Memo and the attached technical assistance document informs applicable agency staff in County Waivers Agencies, Managed Care Organizations (MCOs) and Aging and Disability Resource Centers (ADRCs) of how these changes affect the processing of Family Care and Home and Community Based Waiver applications or recertifications.

Policy

Effective immediately, the following types of bills may not be used as medical/remedial expenses to offset the cost-share or to meet the spenddown obligation in the eligibility determination process in Family Care (both at the nursing home and non-nursing home level of care), Partnership, and in the Home and Community Based Waivers:

  1. Medical bills which remain unpaid, but were previously used to meet a Medicaid deductible;
  2. Bills which were for the cost of institutional care provided during a previous Medicaid divestment penalty period;
  3. Bills that represent a patient liability amount/cost share incurred during some previous period of institutionalization and Medicaid eligibility or an unpaid Medicaid Home and Community Based Waiver/Family Care or Partnership cost-share obligation.
  4. Medical bills which will be paid by a legally liable third party, e.g. private health insurance, Medicare, Medicaid, etc.
  5. Medical bills which were previously allowed as a medical/remedial expense and counted to reduce a waiver cost share or used to reduce a nursing home patient liability obligation.

A technical assistance document illustrating example for each situation stated above is attached.

Action Required: Effective immediately, the disallowed medical/remedial expenses described in this memo cannot be used when processing eligibility for Family Care, Partnership and Home and Community Based Waivers, or Institutional Medicaid. The policy applies to new applications and to current participants/enrollees at review/certification time.

REGIONAL OFFICE CONTACT: Human Services Area Coordinators

CENTRAL OFFICE CONTACT: Rita Cairns
Bureau of Long-Term Support
P. O. Box 7851
Madison, WI 53707-7851
608-266-6891
cairnri@wisconsin.gov

MEMO WEB SITE: http://www.dhs.wisconsin.gov/dsl_info/

Attachment: Technical Assistance Document (PDF 25 KB)

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