Beginning September 8, 2015, the VaCMS will evaluate individuals for a Medically Needy Spenddown if they are found ineligible for certain ABD- or MAGI-based Medicaid programs due to income.

Medically Needy Spenddowns require a resource evaluation. However, the client may not have provided any or all resource information during the application process. This is especially true for individuals applying for MAGI-based MA, as resources are not required for MAGI-based MA.

The VaCMS may create a spenddown without collection of the necessary resource information. As such, workers will need to take certain steps to follow up with the customer before completing the full evaluation.

Note: Because individuals requesting MAGI MA do not provide resource information, the below procedure will apply to any individuals who may be eligible for the below F&C Medically Needy Aid Categories. However, this procedure may also apply to an ABD customer if they do not provide the necessary resource information at initial application.

• MA – F&C MN PG

• MA – F&C MN < 18

• MA – F&C MN < 21

1. Check other sources to see if the customer has any additional income or resources beyond what they have already reported.
2. Determine if they can be verified without customer contact.
3. If additional verified income and resource information is found, enter it in Data Collection and rerun eligibility.
4. Create a manual Notice of Action denying the individual(s) for MAGI coverage with a denial reason of “over income.”
5. Send the customer the following forms:
   1. The manual NOA
   2. Appendix E (MAGI customers) or Appendix D (ABD customers)
   3. Spenddown Fact Sheet
   4. Any other forms required to verify income and resources.
6. Give the customer 10 calendar days to return information to evaluate for Spenddown.
   1. If the customer returns all information needed for the Spenddown, evaluate for Medically Needy coverage in VaCMS by entering all additional / new information necessary to evaluate, determine eligibility, and send appropriate notices.
   2. If the customer returns Appendix D / E or other income / resource information, but further clarification or additional verification is needed, send a Manual Checklist of Needed Verifications with a 10-day due date.
   3. If the customer does not return all information required to evaluate for a Spenddown by the final due date, deny the customer for failure to provide information to determine eligibility.
      1. If all members requesting do not provide enough information to determine eligibility, deny through Program Request.
      2. If only certain members cannot be evaluated but others can, change the members’ Program Request from Yes to No.
         

Note: The system-generated Notice of Action may display the incorrect eligibility result. You must suppress the original Notice of Action, then generate and send a revised manual notice to the client.

7. Document any actions taken in the Case Narrative.

TBD

Updated: 09/17/2016