HP Provider Relations October 2010 Spend-down

Spend-downOctober Agenda –Objectives –Spend-down Rule –Spend-down Eligibility –Eligibility Verification System –Enhanced Spend-down Information –Billing a Member –Claims Processing –Examples of Application of Spend-down –Quiz –Helpful Tools –Questions & Answers

Spend-downOctober Objectives –To provide a thorough explanation of spend-down rules and eligibility –To explain when it is appropriate to bill Medicaid members for spend-down –To outline claims processing procedures related to spend-down –To provide illustrative examples of how spend-down calculations are made

Spend-downOctober Spend-down Rule 405 IAC – Providing services to members enrolled under the Medicaid spend-down provision –Subsection (d) states: A provider may not refuse service to a Medicaid member pending verification that the monthly spend-down obligation has been satisfied A provider may not refuse service to a Medicaid member solely on the basis of the member’s spend-down status

Define Spend-down eligibility

Spend-downOctober Spend-down Eligibility –405 IAC – Spend-down eligibility Certain types of income are counted in determining Medicaid eligibility Income greater than a certain threshold is considered "excess income” and is referred to as "spend-down obligation" –Spend-down, therefore, is very similar to a "deductible" The Medicaid member is liable for their initial Medicaid expenses each month, up to their spend- down amount Spend-down amounts are deducted from the first claim(s) processed each month  Pharmacy providers that bill claims on a point of sale (POS) system receive immediate claim adjudication and may collect the amount of spend-down credit at the time of service

Spend-downOctober Spend-down Eligibility –Spend-down members are in the Traditional Medicaid, fee-for service program –Spend-down members should not be in Care Select or the risk- based managed care (RBMC) program

Spend-downOctober Error Codes 0387 and 0388 –Providers may have encountered claim denials due to explanation of benefit (EOB) codes 0387 or 0388 – This service is not payable. The recipient has not satisfied spend-down for the month. –Providers should notify their field consultant when claims deny for these error codes. Note:Claims adjudicate to a paid status when spend-down is credited on a claim. Spend-down-related claims should not adjudicate to a denied status.

Spend-downOctober Eligibility Verification System –Enhanced spend-down information became available on the Eligibility Verification System (EVS) beginning January 1, 2010 –Enhanced spend-down information is available on the following EVS tools: Web interChange Omni Automated Voice Response (AVR) Health Insurance Portability and Accountability Act (HIPAA) 270/271 electronic transactions –Review Bulletin BT for detailed informationBT Enhanced spend-down information

Spend-downOctober Eligibility Verification System –Spend-Down – Yes –Remaining Obligation For This Month – $ –This amount is based on claims processed at the time of this eligibility verification It is subject to change at any time following this eligibility verification as claims continue to process in the system A provider may bill a member for the spend-down amount deducted from the adjudicated claim; however, with the exception of point of sale (POS) pharmacy claims, the member is not required to pay the provider until the member receives the monthly Medicaid Spend-down Summary Notice listing the amount applied to spend-down Enhanced spend-down information

Spend-downOctober Eligibility Verification System Enhanced spend-down information

Learn Billing a member

Spend-downOctober Billing a Member –A provider may bill a member for the dollar amount identified beside Adjustment Reason Code (ARC) 178 on the Remittance Advice (RA) statement –This amount will also show up in the "Patient Responsibility" column

Spend-downOctober Billing a Member –The member is not obligated to pay the provider until the member receives the Medicaid Spend-down Summary Notice listing the amount applied to spend-down Notices are sent on the second business day following the end of the month The notices give a detailed itemization of how the spend-down was applied for that month, including provider name, amounts, and dates of service

Spend-downOctober Billing a Member –Providers should always review the second-to-last page of the Remittance Advice to see if ARC 178 applies to any claims on the RA This page lists all adjustment reason codes present on the RA –ARC 178 indicates there is a spend-down amount billable to at least one member on that week's RA –Examples: 132PREARRANGED DEMONSTRATION PROJECT ADJUSTMENT 178PATIENT HAS NOT MET THE REQUIRED SPEND-DOWN REQUIREMENTS 18DUPLICATE CLAIM/SERVICE 24CHARGES ARE COVERED UNDER A MANAGED CARE PLAN 94PROCESSED IN EXCESS OF CHARGES B5COVERAGE/PROGRAM GUIDELINES WERE NOT MET OR WERE EXCEEDED

Spend-downOctober Billing a Member –Providers must bill their usual and customary charge to the Indiana Health Coverage Programs (IHCP) –Members cannot be billed for more than their spend-down amount

Spend-downOctober Billing a Member –Providers may discharge a member from their care if a member does not adhere to established payment arrangements of outstanding copayments or spend-down –Providers cannot be more restrictive with spend-down members than with other patients

Explain Claims processing

Spend-downOctober Claims Processing –The first claim processed by the IHCP applies to spend-down, regardless of the date of service within the month –The system uses the billed amount to credit spend-down –Third Party Liability (TPL) amounts are deducted from billed amount prior to crediting spend-down –State-mandated copayments for pharmacy and transportation claims credit spend-down first

Spend-downOctober Claims Processing The Division of Family Resources may credit spend-down for the following: –Medical expenses incurred by a recipient’s spouse or other person whose income is considered in determining eligibility –Medical services provided by non- Medicaid providers –Services rendered prior to eligibility

Spend-downOctober Claims Processing Hierarchy of spend-down credits: –Non-claim items entered by the caseworker Including spousal medical expenses and expenses for children under age 18 –State-mandated transportation and pharmacy copayments –Denied details, when permitted –Paid details

Spend-downOctober Claims Processing –Services that are not covered by the Medicaid program do not credit spend-down –Exceptions: A service that is denied because the member exceeds a benefit limitation, which cannot be overridden with prior authorization (PA), may credit spend-down Denied services may be split between spend-down months Denied services

Spend-downOctober Claims Processing Date Billed: September 25, 2010 –$ Spend-down Remaining for September –$ Spend-down Remaining for October Benefit Limit Exhausted – Example 1 Billed AmountClaim StatusAuditCredit to Spend-down $200.00Denied6122 – Chiropractic Therapeutic Physical Medicine Treatments Limited to 50 $ – September $ – October

Spend-downOctober Claims Processing Date Billed: September 25, 2010 –$ Spend-down Remaining for October Benefit Limit Exhausted – Example 2 Billed Amount Claim Status AuditCredit to Spend-down Paid to Provider $800.00Denied6238 – Dental Services Limited to $ $ September $0.00 $ rolls forward to October

Spend-downOctober Claims Processing –When a claim is paid and credits the member’s spend-down, a provider-initiated void or replacement can cause an increase or decrease in spend-down amount owed to a provider for the claim –In the event a refund is due to the member as a result of a voided claim, the member is notified in the Medicaid Spend-down Summary Notice The member must have paid the provider to be eligible for a refund –Voids and replacements adjust the spend-down credit immediately Voids and replacements

Spend-downOctober Claims Processing –If the caseworker makes changes to the spend-down amount during the current month or previous month, the total spend-down amount only decreases, never increases –Each month, HP performs a month- end balancing process that ensures all credits applied by the county are used first Month-end balancing

Spend-downOctober Claims Processing –This process ensures that any Indiana Client Eligibility System (ICES) non- claim and claim items and State- mandated copayments are applied correctly –Claims affected by the month-end balancing have an internal control number (ICN) with region code 64 –The amount used to credit spend- down on a claim only decreases by this process Month-end balancing

Spend-downOctober Claims Processing Example 1 – Spend-down Activity for September - $500 Order of Claims that Credit the Spend- down Date of Service Provider Type Amount Incurred Method of Claim Submission Claim Processing Date Claim Status Spend-down Balance for September 19/2/10Pharmacy$50.00 (Includes Copay) Point of Sale (POS) 9/2/10Paid $0.00$ /5/10Physician$100.00Web interChange 9/5/10Paid $0.00$ /8/10Pharmacy$50.00 (Includes Copay) Point Of Sale (POS) 9/8/10Paid $0.00$ /7/10Non- Claim $50.00ICES (County Office) $ /8/10Outpatient Hospital $ I (Electronic) 9/15/10$ Credit spend- down Paid $0.00 $0.00 (Allowed amount is less) 69/2/10Dental$100.00Paper9/20/10Paid IHCP Allowed

Spend-downOctober Claims Processing Example 2 – Spend-down Activity for October - $300 Order of Claims that Credit the Spend- down Date of Service Provider TypeAmount Incurred Method of Claim Submission Claim Processing Date Claim Status Spend- down Balance for October 110/2/10Pharmacy$20.00 (Includes Copay) Point of Sale (10:00 a.m.) 10/2/10Paid $0.00 $ /2/10Physician$50.00Web interChange (2:00 p.m.) 10/2/10Paid $0.00 $ /8/10Dental$100.00Web interChange 10/8/10Paid $0.00 $ /25/10PhysicianVoid of Claim #2 for $50.00 Web interChange 10/25/10Void Entire Claim $ /28/10Dentist$100.00Paper10/15/10Paid $0.00 $ /29/10Transport$150.00Paper10/20/10$80.00 Credit Spend- down $0.00 (Allowed amount is less)

Spend-downOctober Claims Processing Example 3 – Spend-down Activity for June - $400 Order of Claims that Credit the Spend- down Date of Service Provider TypeAmount Incurred Method of Claim Submission Claim Processing Date Claim Status Spend- down Balance for June 16/2/10Pharmacy$50.00 (Includes Copay) Point of Sale (POS) 6/2/10Paid $0.00$ /5/10Physician$100.00Web interChange 6/5/10TPL paid $25.00 Paid $0.00 $ /8/10Pharmacy$50.00 (Includes Copay) Point Of Sale (POS) 6/8/10Paid $0.00$ /8/10Outpatient Hospital $ I (Electronic) 6/15/10Paid $0.00$ /2/10Transport$100.00Paper6/20/10$25.00 Credit $2.00 copay rolls forward) $0.00 (Allowed amount is less)

Spend-downOctober Spend-down Quiz (True or False) –A provider may refuse to provide service to a member if they verify eligibility and determine the member has a spend-down? –A provider may refuse to provide service to a member who has not yet met his or her spend-down obligation for the month? –A provider may refuse to provide a service to a member who has a legitimate past-due balance for a spend-down, but refuses to pay it? –A provider may bill the member for spend-down as soon as they receive a Remittance Advice that includes ARC 178? –A member must pay his or her spend-down obligation at time of service? –Care Select members may have a spend-down? –Spend-down is credited based on the provider’s usual and customary charge? –Members have no way of knowing how their spend-down was applied each month, unless they keep track of it on their own?

Spend-downOctober Spend-down Quiz (True or False) –A provider may refuse to provide service to a member if they verify eligibility and determine the member has a spend-down? FALSE –A provider may refuse to provide service to a member who has not yet met his or her spend-down obligation for the month? FALSE –A provider may refuse to provide a service to a member who has a legitimate past-due balance for a spend-down, but refuses to pay it? TRUE –A provider may bill the member for spend-down as soon as they receive a Remittance Advice that includes ARC 178? TRUE –A member must pay his or her spend-down obligation at time of service? FALSE –Care Select members may have a spend-down? FALSE –Spend-down is credited based on the provider’s usual and customary charge? TRUE –Members have no way of knowing how their spend-down was applied each month, unless they keep track of it on their own? FALSE

Find Help Resources Available

Spend-downOctober Helpful Tools Avenues of resolution –IHCP Web site at –IHCP Provider Manual (Web, CD-ROM, or paper) –Customer Assistance Local (317) All others –Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN –Provider field consultant

Q&A