1. October 2009 Presented by the EDS Provider Field Consultants Automation of Spend-down

2. AUTOMATION OF SPEND-DOWN 2/ OCTOBER 2009 Agenda Introductions Session Objectives Spend-down Rule Overview of Spend-down Population Member Eligibility Billing a Member Eligibility Verification System Claims Processing Medicaid Spend-down Summary Notice Remittance Advice Statement or 835 Helpful Tools Questions and Answers

3. AUTOMATION OF SPEND-DOWN 3/ OCTOBER 2009 Session Objectives At the end of this session, providers will be able to: Understand how the spend-down is credited Identify when a member has a spend-down Understand how claims are affected before and after the spend-down is met Identify when spend-down is credited on a claim Identify the dollar amount credited to spend-down on a claim

4. AUTOMATION OF SPEND-DOWN 4/ OCTOBER 2009 Spend-down Rule 405 IAC 1-1-3.1 – Provide Services to members enrolled in Medicaid spend- down provision 405 IAC 2-3-10 – Spend-down eligibility

5. AUTOMATION OF SPEND-DOWN 5/ OCTOBER 2009 Overview of Spend-down Population

6. AUTOMATION OF SPEND-DOWN 6/ OCTOBER 2009 Number of Members on SLMB Number of Members on Spend-down Only Number of Members on Medicare, but not QMB IHCP 8,419 + 20,097 + 142 + Number of Members on QMB Also and Spend-down 15,203 + 35,442 Data as of July 2009 Overview of Spend-down Population

7. AUTOMATION OF SPEND-DOWN 7/ OCTOBER 2009 Member Eligibility

8. AUTOMATION OF SPEND-DOWN 8/ OCTOBER 2009 Member Eligibility Member is eligible on the first of the month and may have a spouse on Medicaid Providers may not refuse service to a member pending verification of the status of spend-down for the month

9. AUTOMATION OF SPEND-DOWN 9/ OCTOBER 2009 Billing a Member

10. AUTOMATION OF SPEND-DOWN 10/ OCTOBER 2009 Billing a Member A provider may bill a member for the dollar amount identified beside ARC 178 on the Remittance Advice (RA) statement 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

11. AUTOMATION OF SPEND-DOWN 11/ OCTOBER 2009 Billing a Member Members cannot be billed for more than their spend-down amount Providers must bill their usual and customary charge to the Indiana Health Coverage Programs (IHCP)

12. AUTOMATION OF SPEND-DOWN 12/ OCTOBER 2009 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

13. AUTOMATION OF SPEND-DOWN 13/ OCTOBER 2009 Eligibility Verification System

14. AUTOMATION OF SPEND-DOWN 14/ OCTOBER 2009 Eligibility Verification System All historical spend-down information is available on the Eligibility Verification System (EVS) Effective January 1, 2006, the EVS displays a spend- down indicator of “Yes” (member has spend-down) or “No” (member is not on spend-down) The met date only shows for dates of service prior to January 1, 2006 The EVS does not display the member’s monthly spend-down amount

15. AUTOMATION OF SPEND-DOWN 15/ OCTOBER 2009 Web interChange

16. AUTOMATION OF SPEND-DOWN 16/ OCTOBER 2009 Claims Processing

17. AUTOMATION OF SPEND-DOWN 17/ OCTOBER 2009 Claims Processing If a spend-down met date is on file If no spend-down met date is on file Dates of Service Prior to January 1, 2006: Form 8A is required if Date of Service = Met Date System uses the automation process Dates of Service On or After January 1, 2006: Spend-down met date no longer applies Form 8A is no longer required Claims credit spend- down based on the order claims are processed Claims process directly through the system

18. AUTOMATION OF SPEND-DOWN 18/ OCTOBER 2009 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

19. AUTOMATION OF SPEND-DOWN 19/ OCTOBER 2009 Claims Processing The combined total of the Medicare coinsurance, psychiatric reduction, deductible, and blood deductible amounts credit spend-down Claims for Medical Review Team (MRT) and Pre- admission Screening and Resident Review (PASRR) do not credit spend-down because they are not Medicaid claims and do not apply to spend-down processing

20. AUTOMATION OF SPEND-DOWN 20/ OCTOBER 2009 Claims Processing The Division of Family Resources may credit spend- down for the following: Medical expenses incurred by a spouse of a member Services provided by non-Medicaid providers CHOICE Services rendered prior to eligibility

21. AUTOMATION OF SPEND-DOWN 21/ OCTOBER 2009 Claims Processing Hierarchy of spend-down credits: Nonclaim 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

22. AUTOMATION OF SPEND-DOWN 22/ OCTOBER 2009 Claims Processing Medicaid is responsible for the Medicare coinsurance and deductible amounts –These amounts do not credit spend-down Noncrossover claims credit spend-down based on spend-down policy –Medicare noncovered services are not crossover claims Qualified Medicare Beneficiaries – QMB Also with Spend-down

23. AUTOMATION OF SPEND-DOWN 23/ OCTOBER 2009 Claims Processing Services that are not covered by the Medicaid program do not credit spend-down 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

24. AUTOMATION OF SPEND-DOWN 24/ OCTOBER 2009 Claims Processing Date Billed: September 25, 2009 $100.00 Spend-down Remaining for September $200.00 Spend-down Remaining for October Billed Amount Claim StatusAuditCredit to Spend-down $200.00Denied6122 – Chiropractic Therapeutic Physical Medicine Treatments Limited to 50 $100.00 – September $100.00 – October Benefit Limit Exhausted – Example 1

25. AUTOMATION OF SPEND-DOWN 25/ OCTOBER 2009 Claims Processing Date Billed: September 25, 2009 $700.00 Spend-down Remaining for October Billed Amount Claim Status AuditCredit to Spend- down Paid to Provider $800.00Denied6238 – Dental Services Limited to $600.00 $700.00 September $0.00 $100.00 rolls forward to October Benefit Limit Exhausted – Example 2

26. AUTOMATION OF SPEND-DOWN 26/ OCTOBER 2009 Claims Processing System edits are in place to ensure paid claims do not credit spend-down more than once System edits are in place to ensure denied claims that credit spend-down do not credit more than once Preventing Duplicate Credits to Spend-down

27. AUTOMATION OF SPEND-DOWN 27/ OCTOBER 2009 Claims Processing Header Level – Prorate per day –Inpatient –Long Term Care –Crossovers Detail Level – Credit applied based on the ‘From’ date of service –CMS-1500 –Outpatient (UB-04) –Home Health (UB-04) –Dental (ADA 2006 ) Claims that Span More Than One Month

28. AUTOMATION OF SPEND-DOWN 28/ OCTOBER 2009 Claims Processing Example: Billed amount = $100,000 Number of Days billed = 25 $100,000 / 25 = $4,000 - per day credits spend-down Prorating Inpatient Days That Span Months

29. AUTOMATION OF SPEND-DOWN 29/ OCTOBER 2009 Claims Processing For detail-level claims, whenever possible, providers should bill services for different months on separate detail lines By billing in this manner, the maximum amount possible credits the member’s spend-down per month Span Dates - Detail

30. AUTOMATION OF SPEND-DOWN 30/ OCTOBER 2009 Claims Processing Example 1 - $100.00 credited toward July only Paid Detail 1: From Date of Service To Date of Service Billed Amount 7/31/09 8/2/09$100.00 Span Dates

31. AUTOMATION OF SPEND-DOWN 31/ OCTOBER 2009 Claims Processing Example 2 - $25.00 toward July $75.00 toward August Paid Detail 1: From Date of ServiceTo Date of Service Billed Amount 7/31/09 7/31/09$25.00 Paid Detail 2: From Date of Service To Date of Service Billed Amount 8/1/09 8/02/09 $75.00 Span Dates

32. AUTOMATION OF SPEND-DOWN 32/ OCTOBER 2009 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

33. AUTOMATION OF SPEND-DOWN 33/ OCTOBER 2009 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, EDS performs a month-end balancing process that ensures all credits applied by the county are used first Month-End Balancing

34. AUTOMATION OF SPEND-DOWN 34/ OCTOBER 2009 Claims Processing This process ensures that any Indiana Client Eligibility System (ICES) nonclaim 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

35. AUTOMATION OF SPEND-DOWN 35/ OCTOBER 2009 Example 1: Spend-down Activity for September - $500.00 Order of Claims that Credit the Spend- down Date of Service Provider TypeAmount Incurred Method of Claim Submission Claim Processing Date Claim StatusSpend- down Balance for September 19/2/09Pharmacy$50.00 (Includes Copay) Point of Sale (POS) 9/2/09Paid $0.00$450.00 29/5/09Physician$100.00Web interChange 9/5/09Paid $0.00$350.00 39/8/09Pharmacy$50.00 (Includes Copay) Point Of Sale (POS) 9/8/09Paid $0.00$300.00 49/7/09Non-Claim$50.00ICES (County Office) $250.00 59/8/09Outpatient Hospital $300.00837I (Electronic) 9/15/09$250.00 Credit spend-down Paid $0.00 $0.00 (Allowed amount is less) 69/2/09Dental$100.00Paper9/20/09Paid IHCP Allowed Claims Processing

36. AUTOMATION OF SPEND-DOWN 36/ OCTOBER 2009 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 October 110/2/09Pharmacy$20.00 (Includes Copay) Point of Sale (10:00 a.m.) 10/2/09Paid $0.00 $280.00 210/2/09Physician$50.00Web interChange (2:00 p.m.) 10/2/09Paid $0.00 $230.00 310/8/09Dental$100.00Web interChange 10/8/09Paid $0.00 $130.00 410/25/09PhysicianVoid of Claim #2 for $50.00 Web interChange 10/25/09Void Entire Claim $180.00 510/28/09Dentist$100.00Paper10/15/09Paid $0.00 $80.00 610/29/09Transport$150.00Paper10/20/09$80.00 Credit Spend- down $0.00 (Allowed amount is less) Example 2: Spend-down Activity for October - $300.00 Claims Processing

37. AUTOMATION OF SPEND-DOWN 37/ OCTOBER 2009 Order of Claims that Credit the Spend- down Date of Service Provider Type Amount Incurred Method of Claim Submission Claim Processing Date Claim StatusSpend- down Balance for June 16/2/09Pharmacy$50.00 (Includes Copay) Point of Sale (POS) 6/2/09Paid $0.00$350.00 26/5/09Physician$100.00Web interChange 6/5/09TPL paid $25.00 Paid $0.00 $275.00 36/8/09Pharmacy$50.00 (Includes Copay) Point Of Sale (POS) 6/8/09Paid $0.00$225.00 46/8/09Outpatient Hospital $200.00837I (Electronic) 6/15/09Paid $0.00$25.00 56/2/09Transport$100.00Paper6/20/09$25.00 Credit $2.00 co- pay rolls forward) $0.00 (Allowed amount is less) Example 3: Spend-down Activity for June - $400.00 Claims Processing

38. AUTOMATION OF SPEND-DOWN 38/ OCTOBER 2009 Medicaid Spend-down Summary Notice

39. AUTOMATION OF SPEND-DOWN 39/ OCTOBER 2009 Medicaid Spend-down Summary Notice Notices are sent to the member on the second business day following the end of the month The notice includes a calendar month’s worth of spend-down activity

40. AUTOMATION OF SPEND-DOWN 40/ OCTOBER 2009 Remittance Advice Statement or 835 The Remittance Advice statement and 835 clearly identify amounts credited to spend-down, including any member co- payments that are used to credit spend- down Providers refer to ARC 178 on the Remittance Advice and 835 for the amount credited to spend-down on the claim

41. AUTOMATION OF SPEND-DOWN 41/ OCTOBER 2009 Remittance Advice Statement or 835 Specific adjustment reason codes (ARCs) identify the exact amount used for each header level of detail level service. ARC 178 – Payment Adjusted Because…Spend-down $117.75 ARC 132 – Prearranged Demonstration… $-60.75 ARC A2 – Contractual Adjustment $60.75 ARC 3 – Co-Payment Amount $3.00 Adjustment Reason Codes

42. AUTOMATION OF SPEND-DOWN 42/ OCTOBER 2009 Helpful Tools IHCP Web site at www.indianamedicaid.com www.indianamedicaid.com IHCP Provider Manual (Web, CD- ROM, or paper) HCBS Waiver Provider Manual (Web) Customer Assistance –1-800-577-1278, or –(317) 655-3240 in the Indianapolis local area Written Correspondence –P.O. Box 7263 Indianapolis, IN 46207-7263 Provider Relations Field Consultant Avenues of Resolution

43. AUTOMATION OF SPEND-DOWN 43/ OCTOBER 2009 Questions

44. October 2009 EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people. © 2009 Hewlett-Packard Development Company, LP. Office of Medicaid Policy and Planning (OMPP) 402 W. Washington St, Room W374 Indianapolis, IN 46204 EDS, an HP Company 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204